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Columbia  ZHnibersiitp 
intljeCitpof^etDgorfe 

College  of  $i)p!a;tdan£(  anb  burgeons; 


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THE  TREATMENT  OF  SOME  ACUTE 
VISCERAL    INFLAMMATIONS 

AND   OTHER   PAPERS 


"  Let  me  glean,  I   pray  you,  and  gather  after  the  reapers 
among  the  sheaves." 

"  eKcarov  to  epyov  biroibv  iariv  to  irvp  doKL/mda-ei.." 


THE 

TREATMENT   OF   SOME  ACUTE 
VISCERAL  INFLAMMATIONS 

AND   OTHER  PAPERS 


By    DAVID    B.    LEES 

M.A.,  M.D.Cantai?.,  F.R.C.P.LoNi). 

FORMERLY  SCHOLAR  OF  TKINITV  COLLKOK,  CAMKRIDOK; 
SENIOR  PHYSICIAN  TO  THE  HOSPITAL  FOR  SICK  CHILDREN, 
GREAT  ORMOND  STREET;     PHYSICIAN  TO  ST  MARY's  HOSPITAL. 

LATE  EXAMINER  IN    MEDICINE  FOR  THE  UNIVERSITY  OK  CAMBRIDGE, 
THE   TNIVERRITV   OF   DURHAM,    THE   VICTORIA    UNIVERSITY,    AND    THE 
CONJOINT   BOARD  FOR  ENGLAND. 


PHILADELPHIA  : 
P.   BLAKISTON'S   SON,   &   CO. 

IOI2   WALNUT   STREET 
1904 


Printed  in  Great  Britain 


PREFACE 

The  first  part  of  this  book  consists  of  three  Lectures, 
delivered  before  The  Harveian  Society  of  London  in 
November  1903.  The  ideas  which  they  embody  are 
mainly  these  four  : — 

1st.  The  necessity  for  a  more  careful,  systematic, 
and  repeated  determination,  by  light  percus- 
sion, of  the  size  of  the  left  ventricle  and  of  the 
right  auricle,  in  all  diseases  of  the  heart  and 
of  the  lungs. 

27ul  The  importance  of  relieving  a  distended  right 
heart  by  leeches  or  moderate  venesection. 

p'd.  The  value  of  the  external  application  of  ice 
as  a  local  remedy  in  Pneumonia,  in  Pericar- 
ditis, in  Pleurisy,  in  many  cases  of  Appendi- 
citis, and  in  Acute  Nephritis. 

4^/j.  The  advantage  of  largely  increasing  the 
amount  of  Sodium  Salicylate  given  in  Acute 
Rheumatism  and  in  Chorea,  and  the  necessity 
for  safeguarding  these  larger  doses  by  still 
larger  doses  of  Sodium  Bicarbonate. 


vi  PREFACE 

The  papers  which  follow  have  been  reprinted, 
partly  because  they  show  the  gradual  evolution  of 
the  ideas  above  enumerated,  and  partly  because 
they  deal  with  cognate  subjects.  Among  other 
points,  they  draw  attention  to  the  dilatation  of  the 
left  ventricle,  which  is  constant  in  acute  and  sub- 
acute rheumatism,  and  to  the  still  more  dangerous 
dilatation,  which  is  prone  to  occur  in  diphtheria  and 
in  influenza,  also  to  the  acute  dilatation  of  the  right 
auricle,  which  is  met  with  occasionally  in  mitral 
stenosis ;  and  they  suggest  appropriate  treatment 
for  these  several  conditions. 

They  include  also  a  description  of  the  earliest 
manifestations  of  rheumatic  heart-disease,  and  of 
the  clinical  phenomena  of  chorea. 

Two  pathological  specimens  are  also  described — 
a  remarkable  congenital  malformation  of  the  heart, 
and  a  rare  abnormality  of  the  larynx   in  an  infant. 

Finally,  it  is  claimed  that  a  study  of  the  dyspnoea 
associated  with  dilatation  of  the  right  heart  affords 
proof  of  the  existence  of  a  true  reflex  from  the  right 
ventricle  to  the  respiratory  centre,  of  which  there  is 
as  yet  no  evidence  from  physiological  experiment. 

My  hope  is  that  some  at  least  of  these  papers  may 
be  found  to  be  of  permanent  value. 

D.  B.  L. 

April  1904. 


CONTENTS 

PAGE 

Lecture      I. — Carditis  and  Pericarditis  .  .  5 

Lecture    IL — Pneumonia       .  .  .  .38 

Lecture  I  IL— Pneumonia,    Empyema,    Pleurisy, 

Appendicitis,  Nephritis  ...         70 


OTHER    PAPERS 

1.  Case  of  Malformation   of  the   Heart,  with   Trans- 

position  of   the  Aorta  and    Pulmonary  Artery. 
{Pathological  Tj'ansactions^   1880)  .  .         10 1 

2.  Larynx  from  an  Infant  which  had  been  the  subject 

of  a  Peculiar  Form  of  Obstructed  Inspiration. 
{Pathological  Transactions^  1883)  .  .         no 

3.  Two    Cases    of    Bronchopneumonia    treated    with 

Bleeding   and    Ice.      {British  Medical  Journal^ 

nth  July  1885)       .  .  .  .  .113 

4.  Presystolic  Apex- Murmur  due  to  Aortic  Regurgita- 

tion.    {America?!  Jour?2al  of  the  Medical  Sciences^ 


5.  The   Icebag  as   a   Therapeutic  Agent.       {Clinical 

Journal,  Vol.  L,  No.  i,  1892)       .  .  .148 


iii  CONTENTS 

6.  A  Clinical  Lecture  at  St  Mary's  Hospital  on  a  Case 

of  Chorea  and  Pericarditis  ;  a  Case  of  General 
Paralysis  of  the  Insane  ;  a  Case  of  Mitral  Disease 
with  Spasmodic  Dyspnoea ;  and  a  Case  of  Car 
diac    Dilatation.        {Clinical  Journal,    Vol.    I 
No.  19,  1893)  .... 

7.  Is     there     a      Dextrocardiac-Respiratory    Reflex 

{Laftcel,  28th  October  1893) 

8.  Acute  Dilatation  of  the  Heart  in  Rheumatic  Fever, 

{Medico-Chirurgical  Transactions,  1898) 

9.  Rheumatic  Heart-Disease  in  Children  :  the  Intro- 

duction to  a  Discussion  in  the  Section  of  Diseases 
of  Children  at  the  Edinburgh  Meeting  of  the 
British  Medical  Association.  {^British  Medical 
Journal,  il 


165 


181 


10.  An  Address  on  Acute  Dilatation  of  the  Heart  in 

Diphtheria,  Influenza,  and  Rheumatic  Fever, 
delivered  before  the  Manchester  Medical  Society. 
{British  Medical  Journal,  1901)      .  .  .         231 

11.  A  Presidential  Address  on  the  Heart  of  the  Child, 

delivered  before  the  Harveian  Society.     {Laiuet, 

1902)  .  .  .  .  .  .         252 

12.  The   Pathology  and    Treatment    of    Chorea  :    the 

Introduction  to  a  Discussion  in  the  Section  of 
Diseases  of  Children  at  the  Swansea  Meeting 
of  the  British  Medical  Association.  {British 
Medical  Journal,  1903)      .  .  .  .275 


Index        .......       298 


THE  TREATMENT  OF  SOME  ACUTE 
VISCERAL  INFLAMMATIONS 

INTRODUCTION 

k  Acute  inflammation  of  one  or  more  of  the  thoracic 
and  abdominal  viscera,  usually  bacterial  in  origin, 
confronts  the  practitioner  of  medicine  almost  every 
day  and  gives  him  many  anxious  moments.  It  is 
often  fatal,  cutting  short  many  useful  and  valued  lives, 
and  thus  causing  the  deepest  sorrow  and  often  also 
pecuniary  disaster  to  individuals  and  to  families. 
When  not  fatal,  it  may  result  in  a  condition  of  chronic 
disease  and  incapacity,  the  effects  of  which  may  be 
felt  as  long  as  the  patient  lives. 

The  nature  of  the  diseases  thus  caused  is  better 
understood  than  it  was  twenty  years  ago,  and  much 
valuable  work  has  been  done  for  their  elucidation. 
But  it  cannot  be  said  that  a  similar  advance  has  been 
made  in  their  treatment,  or  that  they  are  now,  to  any 
considerable  extent,  less  fatal  than  of  old.  Pneumonia 
still  too  often  destroys  life  in  a  few  days,  and  has  even 
gained  a  fiercer  virulence  by  its  alliance  with  influenza, 

A 


2  INTRODUCTION 

The  acute  inflammations  of  the  heart  and  kidneys 
still  result  in  shortened,  crippled,  and  distressful  lives. 
There  is  an  urgent  need  for  improvement  in  the 
treatment  of  these  acute  visceral  inflammations.  The 
present  methods  are  largely  traditional,  and  unfortun- 
ately these  traditions  are  often  incorrect  and  founded 
on  inaccurate  observation. 

To  advocate  measures  of  different  nature  is  to 
expose  oneself  to  the  risk  of  being  considered  a 
reckless  and  dangerous  innovator  ;  but  this  risk  must 
be  accepted  if  any  real  improvement  is  to  be  made. 
Any  such  attempt  to  reform  traditional  plans  of  treat- 
ment, if  it  is  to  be  successful,  must  be  founded  on 
long-continued,  patient,  and  careful  observation,  and 
on  experience  of  many  cases. 

In  these  lectures  I  desire  to  state  some  of  the  con- 
clusions to  which  I  have  been  led  by  my  own  attempts 
to  improve  the  treatment  of  acute  visceral  inflamma- 
tions, and  to  describe  the  methods  which  I  have 
employed,  more  or  less  fully,  during  the  last  sixteen 
years  at  St  Mary's  Hospital,  and  for  thirteen  years 
at  the  Hospital  for  Sick  Children,  Great  Ormond 
Street.  The  number  of  beds  under  my  care  has  been 
constantly  about  sixty  :  thirty  for  adults,  and  thirty 
for  children.  My  first  paper  on  the  subject,  entitled 
"  Two  Cases  of  Broncho-Pneumonia  treated  with 
Bleeding  and  Ice,"  was  published  in  1885.  But  my 
interest  in  the  matter  is  of  much  earlier  date.  Twenty- 
nine  years  ago,  while  still  a  medical  student   I  stood 


INTRODUCTION  3 

by  the  deathbed  of  one  dear  to  me  and  dear  to  many, 
the  mother  of  ten  children,  whose  health  had  been 
excellent  until  a  week  before  her  death,  at  only  forty- 
nine,  from  pneumonia.  To  her  memory  I  dedicate 
these  lectures. 


LECTURE   I 

CARDITIS   AND   PERICARDITIS 

It  is  right  to  begin  with  the  heart,  for  the  heart  is 
the  mainstay  of  life.  More  fundamental  than  the 
respiration,  the  digestive,  assimilative,  and  excretory 
apparatus,  or  the  nervous  centres  and  paths,  is  the 
wonderful  rhythmic  contraction  of  the  cardiac  mus- 
cular fibre.  Cardiac  pulsation  begins  as  early  as  the 
second  day  of  embryonic  life  in  the  chick,  very  soon 
after  the  first  appearance  of  a  rudimentary  heart,  and 
"  long  "  (say  Foster  and  Balfour)  "  before  the  cells  of 
which  it  is  composed  show  any  distinct  differentiation 
into  muscular  or  nervous  elements."  The  pulsation 
continues  throughout  the  whole  of  the  subsequent 
life,  and  physiology  now  teaches  that  it  is  not  the 
cardiac  nerves  or  ganglia,  but  the  automatic  rhythmic 
contraction  of  the  cardiac  muscle,  which  maintains  the 
circulation.  When  this  ceases,  nothing  can  prolong 
our  life.  How  marvellous — and  how  little  regarded  ! — 
is  this  physiological  miracle,  the  persistent  automatic 
rhythmic  discharge  of  cardiac  energy,  independent  of 
volition  and  of  consciousness,  once  in  every  second  or 

5 


6  CARDITIS  AND  PERICARDITIS  [lect. 

thereabouts,  perhaps  for  eighty  or  ninety  years  !  In 
the  course  of  a  long  life  the  heart  will  have  performed 
three  thousand  million  contractions,  and  executed  an 
amount  of  work  equal  to  the  raising  through  a  height 
of  one  foot  no  less  than  2  J  millions  of  tons.  When 
we  have  realised  these  facts  we  see  what  a  calamity 
an  acute  cardiac  inflammation  or  degeneration  must 
be,  and  how  it  must  almost  necessarily  shorten  life 
and  enfeeble  activity. 

If  the  cardiac  muscular  fibre  is  to  continue  its 
regular  rhythmic  action,  two  conditions  are  essential. 
First,  the  wall  of  the  heart  must  be  adequately 
nourished  by  the  circulation  therein  of  sufilicient  blood 
of  normal  quality,  and  secondly,  the  internal  tension 
in  the  cardiac  cavities  must  be  maintained  within 
certain  limits,  for  a  normal  intracardiac  tension  is  a 
constant  stimulus  to  the  heart,  while  an  excessive 
tension  may  dilate  it  and  greatly  diminish  the  force 
of  its  contractions.  Acute  inflammation  of  the  heart 
interferes  with  both  these  conditions.  It  deranges 
the  circulation  of  blood  in  the  cardiac  wall,  and  alters 
the  composition  of  the  blood  supplied  to  it.  Secondly 
an  acute  inflammation  of  the  heart  alters  the  tension 
in  the  cardiac  cavities,  reducing  the  tension  in  the  left 
ventricle  and  increasing  it  in  the  right,  through  the 
enfeeblement  of  the  ventricles  by  the  inflammatory 
process,  which  causes  a  gradual  stagnation  of  blood 
in  the  pulmonary  circuit  and  right  heart.  But  further, 
an  acute  inflammation  of  the  heart  not  only  hinders 


I.]       CAUSES  OF  CARDIAC  INFLAMMATION         7 

its  efficiency :  it  tends  to  injure  and  destroy  the 
cardiac  muscular  fibre  itself.  The  fibres  are  com- 
pressed by  the  inflammatory  products  in  the  inter- 
stitial connective  tissue,  and  at  the  same  time  poisoned 
by  toxins  in  the  blood.  Hence  more  or  less  fatty 
degeneration  and  consequent  atrophy  of  the  cardiac 
muscle  occurs,  and  a  tendency  to  fibrosis  results  from 
the  interstitial  inflammation.  The  fibrous  structure 
of  the  heart  suffers  as  well  as  the  muscular.  The 
valves  are  swollen  and  deformed,  causing  hindrance 
to  the  onward  flow  of  the  blood,  or  regurgitation,  or 
both.  The  pericardial  covering  of  the  heart  may 
suffer  also,  especially  when  the  myocarditis  is  severe, 
for  the  visceral  pericardium  is  a  part  of  the  heart 
itself 

The  most  frequent  cause  of  acute  inflammation  of 
the  heart  is  the  rheumatic  process,  the  explanation  of 
which  has  now  been  furnished  by  the  brilliant  and 
careful  investigations  of  Poynton  and  Paine.  They 
have  proved  that  from  the  tissues  of  rheumatic 
patients  after  death,  as  well  as  from  their  blood  during 
life,  and  from  "  rheumatic  nodules "  excised  with 
aseptic  precautions,  pure  cultures  can  be  obtained  of 
an  organism  which,  when  injected  intravenously  into 
rabbits,  can  produce  in  them  almost  all  the  various 
manifestations  of  a  virulent  rheumatism  in  a  child. 
This  organism  is  a  diplococcus,  which  grows  like  a 
staphylococcus  on  solid  media,  and  like  a  strepto- 
coccus in  liquid  ones.     It  is  a  point  of  much  interest 


8  CARDITIS  AND  PERICARDITIS  [lect. 

that  the  cultures  ahvays  become  acid,  even  though  the 
culture-medium  be  alkaline  at  first.  Poynton  and 
Paine  have  demonstrated  the  existence  of  these 
organisms  in  the  interior  of  the  cardiac  valves  (with 
intact  epithelium),  also  in  the  interstitial  connective 
tissue  between  the  cardiac  muscular  fibres,  and  in  the 
pericardial  fluid.  The  type  of  inflammation  which 
they  cause  in  the  heart  is  a  fibro-serous  one. 
Much  less  frequent,  yet  more  directly  fatal,  than  the 
rheumatic  diplococcus,  as  a  cause  of  acute  inflamma- 
tion of  the  heart,  are  the  pneumococcus  and  the 
other  pyogenetic  organisms.  These  may  cause  a 
suppurative  pericarditis,  or  a  malignant  endocar- 
ditis; how  far  they  may  affect  the  wall  of  the 
heart  is  not  known.  Suppurative  pericarditis  is  very 
much  less  common  than  rheumatic :  in  many  of  the 
cases  in  which  it  occurs  it  is  associated  with  pneu- 
monia or  with  empyema,  or  is  part  of  a  general 
pyaemia.  It  differs  from  rheumatic  pericarditis  in 
symptoms  and  in  physical  signs,  and  is  often 
extremely  difficult  of  diagnosis.  Its  treatment  differs 
greatly  from  that  of  rheumatic  pericarditis.  The 
tubercle  bacillus  is  rarely  the  cause  of  pericarditis,  and 
this  is  usually  of  chronic  type,  and  often  obscure  in  its 
symptoms  and  signs.  The  diphtheria  bacillus  causes 
by  its  toxin  an  intense  fatty  degeneration  of  the 
cardiac  muscle.  The  pericarditis  of  chronic  nephritis 
is  probably  toxic  in  nature,  and  is  usually  a  terminal 
phenomenon. 


I.]  SODIUM  SALICYLATE  9 

It  is  clear,  therefore,  that  the  treatment  of  acute 
cardiac  inflammation  is,  in  the  great  majority  of  cases, 
the  treatment  of  an  infection  with  the  organism  of 
acute  rheumatism,  and  we  have  to  consider  what 
therapeutic  agents,  general  and  local,  are  available  to 
assist  us. 

First  and  foremost,  we  must  determine  the  value  of 
sodium  salicylate  as  an  internal  remedy  in  acute 
rheumatism.  It  is  believed  by  some  that  the  value  of 
salicylate  in  the  treatment  of  rheumatism  is  limited 
to  the  reduction  of  temperature,  the  relief  of  pain,  and 
the  diminution  of  arthritis.  But  a  very  short  experi- 
ence in  the  wards  of  a  hospital  for  children  suffices  to 
show  that  this  view  is  quite  inadequate.  For  in  the 
rheumatism  of  childhood  arthritis  is  often  absent  alto- 
gether, and  pain  may  be  slight,  while  cardiac  disease 
is  severe.  Yet  the  good  effects  of  salicylate  in 
children  are  quite  as  well  marked  as  in  adults.  The 
temperature  falls,  the  general  condition  improves, 
torpidity  gives  place  to  a  bright  expression,  and  the 
cardiac  state  is  ameliorated,  the  area  of  dullness  tend- 
ing to  diminish,  and  the  strength  of  the  ventricular 
contraction  to  increase. 

Observation  of  the  effects  of  salicylate  in  the  treat- 
ment of  acute  rheumatism  both  in  children  and  in 
adults  has  led  me  to  the  conviction  that  it  is  as  truly 
antirheumatic  as  quinine  is  antimalarial  or  mercury 
antisyphilitic.  But  it  must,  of  course,  be  given  in 
adequate  doses,  and  its  use  must  not  be  relinquished 


10  CARDITIS  AND  PERICARDITIS  [lect. 

too  soon.  To  an  adult,  20  gr.  of  sodium  salicylate 
with  40  gr.  of  sodium  bicarbonate  should  be  given 
every  two  hours  during  the  day  and  every  four  hours 
during  the  night.  To  a  child  of  6  to  10  years  old,  10 
gr.  of  salicylate  and  20  gr.  of  bicarbonate  may  be 
given  at  the  same  intervals ;  this  amounts  to  a  daily 
dose  of  100  gr.  of  salicylate.  After  a  day  or  two,  15 
gr.  of  the  salicylate  with  30  gr.  of  bicarbonate  may  be 
administered,  and  if  necessary  this  may  be  increased 
to  20  and  40  gr.  respectively  ;  the  total  daily  amount 
of  salicylate  will  then  be  150  or  200  gr.  Children 
require  proportionally  larger  doses  than  adults,  for  in 
them  the  rheumatic  infection  is  much  more  intense. 
It  is  rare  for  an  adult  to  die  from  his  first  rheumatic 
attack,  but  this  disaster  is  by  no  means  uncommon 
in  childhood.  Fortunately  children  usually  bear  sali- 
cylate well  ;  in  them  it  seldom  causes  much  vomiting, 
often  none  at  all,  and  they  hardly  ever  complain  of 
the  deafness,  tinnitus,  and  headache  which  are'trouble- 
some  in  adults,  nor  do  they  often  manifest  the  mental 
symptoms  and  the  tendency  to  delirium  which  are 
sometimes  caused  by  the  drug  in  later  life. 

There  is,  however,  one  effect  occasionally  produced 
by  salicylate  which  demands  special  mention,  for  it 
is  a  symptom  of  danger,  and  its  occurrence  should 
lead  to  an  immediate  discontinuance  of  the  drug.  It 
is  a  marked  deepening  of  the  inspirations  (apart  from 
pericarditis),  and  resembles  the  "  air  -  hunger "  of 
diabetic  coma.      In  diabetes  an  incipient  air-hunger 


I.]  VALUE  OF  SODIUM  BICARBONATE  11 

may  sometimes  be  arrested  by  the  administration  of 
large  doses  of  alkalies,  and  in  the  only  fatal  case  of 
salicylic  air-hunger  which  has  come  under  my  own 
observation  the  salicylate  had  been  taken  without  any 
added  alkali.  It  seems  probable  that  the  symptom  is 
due  to  an  action  on  the  respiratory  centre  caused  by 
an  excess  of  acid.  An  addition  of  sodium  bicarbonate 
in  quantity  equal  to  twice  that  of  the  salicylate  in 
each  dose  is  usually  sufficient  to  prevent  the  occur- 
rence of  this  symptom. 

If  for  any  reason,  in  child  or  adult,  it  seems 
necessary  to  discontinue  the  salicylate,  it  should  only 
be  suspended  for  a  few  hours  ;  then  it  should  be 
given  again  in  a  smaller  amount,  and  the  dose  gradu- 
ally increased.  It  is  almost  always  possible  in  this 
way  to  accustom  the  patient  to  the  drug,  and  to  get 
him  to  tolerate  much  larger  doses  than  at  first  pro- 
duced disturbance. 

Case  I. — A  woman,  aged  25,  suffering  from  mitral 
stenosis,  with  high  temperature  and  fresh  endocarditis 
so  severe  as  to  suggest  a  diagnosis  of  malignant 
endocarditis,  vomited  and  became  delirious  on  20-gr. 
doses  of  salicylate.  By  omitting  the  medicine  for  a 
few  hours,  and  then  giving  smaller  doses  at  first,  she 
tolerated  the  remedy  well,  and  it  was  soon  possible  to 
increase  the  amount  as  far  as  30  gr.  every  two  hours. 
The  threatening  signs  and  symptoms  disappeared,  and 
when  she  was  discharged  only  a  tranquil  stenosis 
remained. 

In  severe  cases  large  doses  may  be  necessary,  as 


12  CARDITIS  AND  PERICARDITIS  [lect. 

much  as  30  gr.  every  two  hours  for  an  adult,  occasion- 
ally 25  or  even  30  gr.  for  a  child.  It  is  very  desirable 
to  continue  the  use  of  the  drug  for  a  considerable 
time  after  the  subsidence  of  the  rheumatic  symptoms. 
Too  early  discontinuance  of  the  remedy,  or  a  too 
great  reduction  of  the  dose,  is  often  in  adults,  and 
still  more  frequently  in  children,  quickly  followed  by 
a  relapse.  Too  great  timidity  in  the  employment  of 
salicylate  may  cause  an  adult  patient  additional  pain 
which  might  have  been  avoided ;  in  a  child  it  may  be 
the  cause  of  a  cardiac  disaster. 

Case  1 1. — A  boy,  aged  5,  with  a  greatly  dilated 
rheumatic  heart,  was  treated  with  8  gr.  of  sodium 
salicylate  and  16  gr.  of  bicarbonate  every  two  hours 
for  sixteen  days,  and  manifested  decided  improve- 
ment. The  frequency  of  the  dose  was  then  reduced 
to  every  four  hours,  that  is,  the  daily  dose  of  salicylate 
was  reduced  from  96  gr.  to  48  gr.  Five  days  later, 
while  the  smaller  dose  was  still  being  taken,  a  relapse 
occurred,  with  increased  cardiac  dilatation,  and  this 
led  to  his  death  three  weeks  later. 

Case  III. — A  woman,  aged  52,  suffering  from  rheu- 
matic arthritis  in  many  joints,  and  with  loud  pericardial 
friction,  was  treated  on  lOth  July  1903,  with  200  gr.  of 
sodium  salicylate  daily,  with  400  gr.  of  sodium  bicar- 
bonate, and  an  icebag  was  applied  over  the  heart. 
Four  days  later  the  arthritis  had  disappeared,  and 
the  rub  was  much  less  loud,  though  the  temperature 
had  fallen  only  from  103.5°  to  102°.  But  she  com- 
plained so  much  of  headache,  deafness,  and  tinnitus 
that  the  medicine  was  discontinued  altogether  for 
two  days.     On   i6th  July  it  was  again  given,  but  in 


I.]  ILLUSTRATIVE  CASES  13 

smaller  amount — 120  gr.  of  the  salicylate  and  240  gr. 
of  bicarbonate.  The  temperature  continued  to  fall 
for  two  days  longer,  and  on  the  i8th  was  only  99"; 
but  on  the  19th,  five  days  after  the  temporary  sus- 
pension of  the  remedy,  it  rose  again  to  100.2°,  and 
continued  at  this  height  on  the  20th,  with  a  further 
rise  on  the  21st  to  101.8°.  It  seemed  evident  that  a 
relapse  of  rheumatism  was  coming  on,  which  the 
amount  of  salicylate  and  bicarbonate  then  being 
taken  was  insufficient  to  prevent.  With  a  view  of 
testing  the  question  whether  it  was  the  salicylate  that 
was  really  necessary,  or  whether  an  increased  dose  of 
the  alkali  would  suffice,  the  daily  dose  of  this  was 
raised  to  360  gr.,  the  amount  of  salicylate  being  still 
only  120.  The  temperature  rose  on  that  day  to 
103.4°,  ^i^d  the  next  day  (23rd)  to  103.9°,  ^.nd  fresh 
rheumatic  pain  was  then  felt  in  the  right  hand.  On 
the  24th  the  metacarpo-phalangeal  joints  of  this  hand 
were  red  and  swollen.  It  was  clear  that  the  increase 
in  the  amount  of  alkali  had  failed  to  meet  the  need. 
The  dose  of  salicylate  at  first  given  was  therefore 
resumed,  200  gr.  daily  with  400  of  bicarbonate.  Next 
day  ('25th)  the  redness  and  swelling  of  the  fingers  had 
subsided,  but  on  the  26th  a  fresh  pericardial  rub  was 
heard,  which  was  louder  and  harsher  on  the  27th. 
On  the  28th  it  was  very  much  less,  and  the  tempera- 
ture had  fallen  to  the  normal.  From  26th  July  to 
8th  August  she  took  160  gr.  of  salicylate  and  320  of 
bicarbonate ;  but  as  the  temperature  again  rose  to 
99.5°  on  the  8th  the  doses  were  again  increased  to 
200  gr.  and  400  gr.  There  was  no  further  recurrence 
of  rheumatism,  and  she  now  took  without  difficulty 
the  same  doses  as  had  at  first  caused  disturbance. 
The  temporary  omission  of  the  medicine  and  the 
smaller  subsequent  dose  were  clearly  responsible  for 
this  fresh  rheumatic  outburst  in  joints  and  peri- 
cardium. 


U  CARDITIS  AND  PERICARDITIS  [lect. 

The  employment  of  salicylate  in  sufficient  doses 
for  a  sufficiently  long  period  is  much  hindered  by  a 
tradition  current  among  us  that  this  drug  is  a 
"  cardiac  depressant."  This  doctrine  has  been  main- 
tained by  some  physicians  of  great  authority  as 
clinical  observers,  and  especially  they  have  taught 
that  when  pericarditis  occurs  in  a  patient  suffering 
from  rheumatic  fever  the  salicylate  ought  to  be 
stopped  lest  it  should  depress  the  heart  still  more. 
Now  it  is  clear  that  a  belief  of  this  kind  must  have 
been  founded  on  experience  of  a  tendency  to  failure 
of  the  pulse  and  weakness  of  the  first  sound  of  the 
heart  observed  in  rheumatic  patients  while  taking 
salicylate.  But  one  may  fairly  ask  whether  it  is  quite 
certain  that  such  occurrences  are  really  the  effect  of 
the  drug,  whether  they  may  not  be  due  to  some  other 
cause?  In  the  first  place,  they  may  conceivably  be 
due  to  impurities  of  the  drug  as  administered. 
Especially  in  the  early  years  of  its  use,  when  a  sudden 
demand  arose  for  large  quantities  of  the  new  remedy, 
it  is  quite  likely  that  adulterations  due  to  imperfect 
methods  of  preparation  may  have  caused  toxic 
symptoms,  the  memory  of  which  remained  in  the 
minds  of  those  who  witnessed  them,  and  gave  to  the 
drug  an  evil  reputation  which  has  clung  to  it  ever 
since.  The  sodium  salicylate  now  obtainable  is 
carefully  prepared  and  purified,  and  is  free  from 
impurities  of  cresols,  etc.  That  obtained  from  oil 
of  winter-green   is   more    than   ten   times  as  costly, 


I.]  SALICYLATE  NOT  DEPRESSANT  15 

so  that  its  employment  in  large  doses  is  impracti- 
cable. 

But  there  is  another  and  a  more  important  fact 
which  has  been  the  main  cause  of  the  belief  in  the 
depressing  effect  of  salicylate.  It  is  unquestionable 
that  rapid  extension  of  the  dullness  of  the  left 
ventricle  with  enfeeblement  of  the  first  sound  and 
of  the  pulse  may  occur  in  rheumatic  patients  who  are 
taking  salicylate.  But  is  this  due  to  the  drug  or  in 
spite  of  it  ?  Has  it  caused  these  symptoms  or  merely 
failed  to  prevent  them?  Can  they  be  due  to  the 
disease  itself? 

Acute  rheumatism  produces,  apparently  in  all  cases 
of  the  disease,  more  or  less  dilatation  of  the  left 
ventricle,  with  a  tendency  to  diffusion  and  weakening 
of  the  impulse  and  enfeeblement  of  the  first  sound, 
I  drew  attention  to  this  fact  in  a  paper  on  acute 
dilatation  of  the  heart  in  rheumatic  fever,  followed  by 
a  joint  paper  with  Dr  Poynton  on  the  same  pheno- 
menon as  observed  in  the  rheumatism  and  chorea 
of  childhood,  both  published  in  the  Transactions  of 
the  Royal  Medical  and  Chirurgical  Society  for  1898. 
These  observations  have  not,  so  far  as  I  am  aware, 
been  controverted,  and  they  have  been  confirmed  by 
subsequent  experience. 

In  the  mildest  case  of  subacute  rheumatism  the  dull- 
ness of  the  left  ventricle  hardly  ever  fails  to  reach  the 
nipple-line  ;  usually  it  extends  a  fingerbreadth  beyond 
it.     It  may  attain  to  two  fingerbreadths  to  the  left  of 


16  CARDITIS  AND  PERICARDITIS  [lect. 

the  nipple-line,  without  any  murmur,  and  it  may 
return  to  the  normal  as  the  attack  subsides.  This 
dilatation  is  due,  no  doubt,  to  the  toxic  action  on  the 
cardiac  muscle  of  the  toxin  produced  by  the  rheumatic 
organisms,  frequently  also  to  the  actual  presence  in 
the  heart-wall  of  the  organisms  themselves.  We  can 
better  appreciate  the  probable  effect  of  the  toxin  by 
remembering  Dr  Gaskell's  experiments,  recorded  in 
the  third  volume  of  the  Jou7'nal  of  Physiology.  Dr 
Gaskell  found  that  a  dilute  solution  of  lactic  acid 
caused  relaxation  and  "  extreme  dilatation "  of  the 
frog's  ventricle,  and  finally  diastolic  standstill ;  it 
caused  relaxation  also  of  the  vessels.  On  the  other 
hand,  a  dilute  solution  of  sodium  hydrate  caused 
gradual  progressive  contraction  of  the  ventricle  until 
it  remained  persistently  fully  contracted,  and  a  similar 
contraction  of  the  arterioles.  He  investigated  also 
the  action  of  various  drugs,  and  found  that  some  of 
them  acted  upon  the  ventricle  like  soda,  others  like 
lactic  acid. 

It  seems  almost  certain  that  the  toxin  produced  by 
the  rheumatic  cocci  acts  upon  the  ventricle  in  a 
manner  similar  to  that  of  lactic  acid  ;  and  it  is  of 
interest  to  remember  that  cultures  of  these  organisms, 
even  in  an  alkaline  medium,  always  become  acid  ; 
also  to  remember  the  belief  of  many  former  clinical 
observers  that  the  poison  of  acute  rheumatism  is 
lactic  acid  itself  Important  evidence  on  this  question 
has    recently  been    brought   forward    by  Dr    Ainley 


1.]         THE  ACID  TOXIN  OF  RHEUMAIISM         17 

Walker  and  Mr  Ryffel  in  a  report  to  the  Scientific 
Grants  Committee  of  the  British  Medical  Associa- 
tion.* They  state  that  the  "  micrococcus  rheumaticus  " 
produces  formic  acid  in  very  considerable  quantity, 
and  that  this  acid  is  not  only  present  in  the  filtered 
cultures  of  the  organism,  but  can  also  be  extracted 
from  the  bodies  of  the  micro-organisms  themselves. 
From  these,  after  repeated  washings  to  remove 
adherent  traces  of  the  culture  -  fluids,  they  have 
obtained  appreciable  amounts  of  formic  acid.  It 
follows  that  the  processes  concerned  in  its  production 
proceed  within  the  bodies  of  the  micro-organisms 
themselves.  From  a  litre  of  culture-fluid  they  were 
able  to  obtain  about  half  a  gram  of  formic  acid.  In 
addition  to  formic  acid,  the  cultures  and  also  the 
washed  micrococci  contain  at  least  one  other  acid  of 
the  fatty  acid  series,  probably  acetic. 

They  also  succeeded  in  obtaining  formic  acid  from 
the  tissues  of  a  rabbit  suffering  from  acute  arthritis 
due  to  the  inoculation  of  this  micro-organism. 

They  state,  also,  that  while  from  normal  urine 
formic  acid  is  absent  or  occurs  in  traces  only,  formic 
and  probably  another  fatty  acid  are  present  in  appre- 
ciable amounts  in  the  urine  during  the  course  of  acute 
rheumatism,  and  they  have  some  evidence  that  under 
the  salicylic  treatment  of  rheumatism  the  amount  of 
formic  acid  in  the  urine  is  reduced. 

V/ith  regard  to  the  origin  of  the  formic  acid,  they 

*  British  Medical  Journal^  19th  September  1903,  p.  659. 

B 


18  CARDITIS  AND  PERICARDITIS  [lect. 

believe  it  to  be  formed  by  the  micro-organism  by  the 
oxidation  of  sarcolactic  acid  into  acetic  and  formic 
acids  according  to  the  equation  : 

CH3  CHOH  COOH  +  O  =  CH3COOH  +  H.COOH. 

They  add  two  facts  of  much  importance.  They  have 
observed  that  the  micrococcus  rheumaticus  has  a 
haemolytic  action  upon  red  blood-corpuscles  greater 
and  more  rapid  than  that  of  any  other  streptococcus 
which  they  have  yet  examined,  which  explains  the 
rapid  and  considerable  anaemia  of  acute  rheumatism. 
They  have  also  succeeded  in  isolating  an  albumose 
from  cultures  of  the  organism  grown  in  albuminous 
fluids  free  from  albumoses,  which  on  injection  into 
animals  (guinea-pigs  and  rabbits)  rapidly  produces 
marked  pyrexia,  and  leads  to  an  increase  of  tempera- 
ture of  three  or  more  degrees  Fahrenheit,  reaching 
on  one  occasion  105'. 

These  observations  of  Dr  Ainley  Walker  and  Mr 
Ryffel  are  a  justification  of  the  ancient  practice  of 
treating  acute  rheumatism  with  alkalies.  Before  the 
specific  action  of  the  salicylate  was  discovered  the 
alkaline  treatment  of  rheumatism  was  the  most  suc- 
cessful, though  at  that  time  potassium  salts  were 
chiefly  used  and  in  comparatively  small  quantities. 
But  sodium  salts  can  be  given  much  more  freely,  and 
Dr  Gaskell's  observations  on  the  frog's  heart  seem  to 
indicate  that  they  also  tend  to  cause  contraction  of 
the  ventricle.     I    think    that   there   is   some   clinical 


I.]        ACUTE  DILATATION  OF  THE  HEART        19 

evidence  that  this  is  really  the  case  when  they  are 
freely  employed  in  rheumatism. 

If,  then,  the  rheumatic  toxin  always  tends,  more  or 
less,  to  dilate  and  enfeeble  the  left  ventricle,  it  is  not 
surprising  to  find  that  in  some  cases  a  "cardiac 
depression  "  may  manifest  itself  somewhat  suddenly, 
after  the  disease  has  lasted  for  some  days,  or  even  a 
week  or  two.  If  the  patient  is  taking  salicylate  when 
this  occurs,  the  drug  is  almost  certain  to  receive  the 
discredit  of  symptoms  really  due  to  the  disease  itself. 
But  strong  evidence  as  to  their  actual  cause  can  be 
adduced  from  analogy,  for  a  similar  acute  dilatation 
and  enfeeblement,  but  of  a  much  more  dangerous 
kind,  is  met  with  in  some  other  diseases,  notably 
influenza  and   diphtheria. 

I  pointed  out,  in  an  address  on  acute  dilatation 
of  the  heart  in  diphtheria,  influenza,  and  rheumatism, 
delivered  before  the  Manchester  Medical  Society  in 
1900,  and  published  in  the  British  Medical  Journal 
for  5th  January  1901,  that  in  all  these  diseases  an 
acute  cardiac  dilatation  is  not  uncommon,  and  that 
it  may  cause  fatal  syncope  in  diphtheria  and  in 
influenza. 

The  symptoms  before  death  are  pallor,  sometimes 
vomiting,  and  feeble  (perhaps  irregular)  pulse.  The 
physical  signs  are  a  rapid  increase  in  the  heart's  dull- 
ness to  the  left,  which  may  amount  to  an  additional 
fingerbreadth  in  a  few  hours,  diffusion  and  weakening 
of  the  impulse,  with  weakening  of  the  first  sound  and 


20  CARDITIS  AND  PERICARDITIS  [lect. 

of  the  pulse-wave.  After  death  extensive  fatty- 
degeneration  of  the  cardiac  muscle  is  found.  The 
symptoms  of  an  acute  dilatation  in  rheumatism  are 
less  serious  than  those  of  a  similar  condition  in  diph- 
theria and  in  influenza,  probably  because  there  is  less 
destruction  of  the  cardiac  muscular  fibre.  The  acute 
dilatation  of  rheumatism  rarely,  if  ever,  produces  a 
fatal  syncope,  but  it  may  give  rise  to  marked  pallor 
and  to  obvious  changes  in  the  pulse.  In  diphtheria 
an  acute  dilatation  may  occur  at  any  time  during  the 
six  weeks  following  the  onset  of  the  disease.  In 
rheumatism  it  may  occur  as  late  as  two  or  three 
weeks  after  the  onset,  perhaps  later. 

Case  IV. — A  woman,  aged  29,  was  suffering  from 
her  first  attack  of  rheumatism.  It  was  of  a  subacute 
type,  with  but  little  arthritis ;  the  cardiac  dullness 
extended  to  the  nipple-line  but  not  beyond  it,  and 
there  was  no  murmur.  She  was  treated  with  sodium 
salicylate.  After  she  had  taken  this  for  a  fortnight 
with  benefit,  the  house-physician  one  day  observed 
that  the  pulse  was  unusually  weak.  He  percussed 
the  heart  at  once,  and  found  that  the  dullness  of  the 
left  ventricle  now  extended  one  fingerbreadth  beyond 
the  nipple-line,  and  a  short  systolic  murmur  could  be 
heard.  I  confirmed  these  facts  on  the  following  day. 
Here  was  a  case  in  which  it  might  have  been  sug- 
gested that  the  salicylate  had  caused  cardiac  failure. 
But  instead  of  omitting  the  drug  I  ordered  it  to  be 
given  more  frequently,  and  placed  an  iccbag  over  the 
heart.  Immediate  improvement  followed,  and  in  a 
few  days  the  cardiac  dullness  was  normal,  and  the 
faint  murmur  had  disappeared. 


I.]  CAREFUL  PERCUSSION  ESSENTIAL  21 

In  diphtheria  it  cannot  be  doubted  that  an  acute 
cardiac  dilatation  is  due  to  the  disease  itself,  and  not 
to  any  drug  that  has  been  administered.  I  am  con- 
vinced that  in  rheumatism  also  it  is  the  disease  itself 
which  is  responsible  for  cardiac  failures,  and  that 
they  are  not  due  to  the  salicylate.  Indeed,  they  are 
probably  in  many  cases  an  indication  that  an  insuffi- 
cient amount  of  the  drug  has  been  given. 

If  more  care  were  taken  to  determine  the  exact 
size  of  the  left  ventricle  by  careful  light  percussion  at 
the  commencement  of  treatment  and  daily  afterwards, 
an  acute  dilatation  would  be  at  once  detected.  There 
is  little  difficulty  in  this  determination  if  the  fingers 
only  and  not  any  "pleximeter"  are  used  for  per- 
cussion, if  the  part  of  the  finger  percussed  is  the 
terminal  phalanx,  and  the  other  phalanges  are  not 
allowed  to  rest  on  the  thoracic  wall,  and  if  the  per- 
cussion-stroke is  always  light.  It  is  a  primary  duty 
to  determine  this  matter  with  care  whenever  a 
practitioner  is  called  on  to  attend  a  case  of  diphtheria, 
of  influenza,  or  of  rheumatism.  It  is,  I  believe,  the 
neglect  of  this  which  has  caused  salicylate  to  be 
considered  a  cardiac  depressant,  and  thus  has  done 
much  mischief  to  rheumatic  patients,  for  it  has 
deprived  them  of  a  necessary  drug. 

If,  then,  sahcylate  is  not  a  cardiac  depressant,  and  if 
it  is  genuinely  antirheumatic,  it  is  surely  specially 
necessary  in  order  to  counteract  the  most  deleterious 
action  of  rheumatism — its  tendency  to  cause  cardiac 


22  CARDITIS  AND  PERICARDITIS  [lect. 

inflammation.  The  worst  type  of  rheumatic  carditis  is 
associated  with  pericarditis,  and  it  is  here  that  the  drug 
is  most  urgently  needed.  To  withhold  salicylate  from 
a  rheumatic  patient,  child  or  adult,  unless  some  equally 
efficacious  medicine  can  be  substituted  for  it,  is,  in 
my  judgment,  to  do  the  patient  a  grievous  injury. 
In  medicine,  as  in  ordinary  life,  sins  of  omission  are 
more  lightly  regarded  than  sins  of  commission,  but 
they  may  be  quite  as  disastrous. 

In  support  of  my  plea  for  the  employment  of  larger 
doses  of  salicylate  in  the  treatment  of  rheumatic 
conditions,  I  may  mention  that  I  have  lately  found 
great  advantage  in  the  administration  of  large  doses 
of  salicylate  and  bicarbonate  in  many  cases  of  chorea. 
The  small  doses  of  these  remedies  usually  given  in 
this  disease  (50  to  60  gr.  a  day)  are  far  too  small.  If 
the  amount  of  salicylate  given  at  first,  in  divided 
doses,  be  100  gr.  per  diem,  and  this  be  rapidly 
increased  to  150  gr.,  and  if  necessary  to  200,  very 
remarkable  improvement  often  occurs,  as  I  showed  at 
the  discussion  on  chorea  at  the  Swansea  meeting  of 
the  British  Medical  Association.  After  this  discus- 
sion, a  fact  of  interest  was  mentioned  to  me  by  Dr 
McVittie,  of  Dublin,  and  he  kindly  allows  me  to  relate 
it  now.  Through  the  mistake  of  a  chemist,  2-drachm 
doses  of  sodium  salicylate  were  taken  by  a  patient 
three  times  daily  for  a  week,  with  much  benefit,  and 
without  the  occurrence  of  any  unpleasant  symptoms. 
Encouraged  by  this  observation,  Dr   McVittie  pre- 


I.]  ADMINISTRATION  OF  SALICYLATE  23 

scribed  for  another  patient  suffering  from  chronic 
rheumatism,  powders  containing  2-drachm  doses  of 
salicylate,  to  be  taken  three  times  a  day.  The  chemist 
to  whom  the  prescription  was  taken  thought  that  a 
mistake  had  been  made,  and  distributed  2  drachms 
of  the  salicylate,  as  a  total  amount,  among  the  twelve 
powders.  The  patient  took  these  powders,  and  was 
no  better.  Then  he  had  the  prescription  made  up  by 
another  chemist,  who  put  into  the  powders  the  full 
dose  ordered.  In  a  week  the  man  was  well.  In  two 
subsequent  cases  of  chronic  muscular  rheumatism  Dr 
McVittie  observed  complete  relief  of  all  pain  follow 
the  use  of  these  powders,  and  no  unpleasant  symptoms 
were  produced. 

My  conclusion  is  that  sodium  salicylate  has 
certainly  a  marked  antirheumatic  action,  that  a  con- 
siderable daily  dose  of  the  drug  is  essential  to  success, 
that  each  dose  should  be  accompanied  by  twice  as 
large  a  dose  of  sodium  bicarbonate,  and  that  the 
joint  action  of  the  two  drugs  should  be  maintained 
for  some  time  after  the  subsidence  of  the  rheumatic 
symptoms. 

We  have,  therefore,  in  the  free  administration  of 
sodium  salicylate  and  bicarbonate  an  adequate 
method  of  meeting  the  causal  indication  in  the 
treatment  of  rheumatic  inflammation  of  the  heart 
and  pericardium.  It  remains  to  inquire  whether  we 
have  also  any  means  of  directly  diminishing  the 
inflammatory  action  by  local  applications.     The  use 


24  CARDITIS  AND  PERICARDITIS  [lect. 

of  blisters  over  the  precordial  region  was  at  one  time 
a  favourite  method  of  treatment,  and  it  is  at  least 
conceivable  that  the  counter-irritation  of  the  overlying 
skin  may  tend  to  diminish  the  fullness  of  the  vessels 
in  an  inflamed  pericardium.  But  it  is  not  desirable  if 
it  can  be  avoided  to  add  to  the  sufferings  of  a  patient 
who  is  seriously  ill,  and  the  local  effect  of  a  blister 
greatly  impedes  the  necessary  examination  of  the 
heart.  Leeches  applied  to  the  cardiac  area  have  a 
distinctly  beneficial  effect.  They  probably  have  some 
direct  influence  in  draining  the  pericardial  vessels, 
and  they  certainly  cause  a  diminution  of  pressure  in 
the  right  auricle,  which  is  often  of  the  greatest  service. 
But  this  latter  effect  can  be  equally  well  obtained  by 
applying  them  to  any  other  part  of  the  thoracic  wall, 
thus  lessening  the  supply  of  blood  through  the  azygos 
vein  to  the  right  auricle,  and  the  subsequent  examina- 
tion of  the  heart  will  then  not  be  impeded.  The 
most  convenient  place  for  their  application  is  over 
the  lower  anterior  part  of  the  right  chest  below  the 
nipple-level ;  it  is  always  possible  to  arrest  the  flow  of 
blood  by  pressure  against  the  firm  resistance  of  the 
ribs.  But  if  the  leeches  are  applied  over  the  soft 
parts  at  the  epigastrium  there  may  be  very  consider- 
able difficulty  in  arresting  the  flow. 

The  persistent  application  of  cold  to  the  precordial 
region  by  means  of  an  icebag  is  a  powerful  means  of 
repressing  cardiac  inflammation.  In  rheumatic  peri- 
carditis  its   effect   is    unmistakable,   and   often   very 


I.]  LOCAL  APPLICATIONS  25 

striking.  I  have  employed  it  in  nearly  every  case 
under  my  care  during  the  last  eleven  years,  and 
have  found  it  extremely  useful.  At  first  I  was  very 
cautious  in  using  it,  only  applying  it  for  a  short  time, 
lest  the  cold  should  further  depress  a  heart  already 
hampered  by  the  pericardial  inflammation.  What 
led  me  to  employ  it  was  the  observation  that  where 
an  icebag  had  been  applied  for  some  hours  to  a 
pneumonic  lung,  it  was  usually  found  that  the  dull- 
ness at  that  spot  was  less  intense,  and  that  there  was 
a  better  air-entry,  indicating  that  the  vascular  con- 
gestion of  the  lung  beneath  the  icebag  had  been 
lessened.  I  found  also  that  the  symptoms  and 
physical  signs  of  subacute  inflammation  of  the  appen- 
dix vermiformis  were  rapidly  relieved  by  an  icebag, 
and  that  the  same  was  true  of  sciatic  neuritis  of 
recent  origin. 

In  all  these  three  cases  the  direct  local  influence  of 
the  icebag  in  repressing  subjacent  visceral  inflamma- 
tion seemed  undeniable,  and  it  occurred  to  me  that 
possibly  it  might  have  the  same  beneficial  influence 
in  pericarditis.  I  soon  found  that  the  inference  was 
correct,  and  that  there  was  no  danger  of  collapse  if 
two  precautions  were  kept  in  mind. 

One  of  these  precautions  is  that  the  patient  be 
made  quite  warm,  if  necessary  by  hot-water  bottles, 
before  the  icebag  is  applied  to  the  heart,  and  that  the 
warmth  be  maintained  during  the  whole  period  of  its 
application.     The  second  precaution  is  that  the  right 


26  CARDITIS  AND  PERICARDITIS  [lect. 

auricle  shall  not  be  allowed  to  be  overdistended.  A 
few  leeches,  applied  as  already  recommended,  are 
sufficient  to  fulfil  this  condition,  and  it  is  generally 
advisable  to  apply  them  before  the  ice  is  used. 

If  these  two  conditions  are  secured,  the  icebag  may 
be  used  without  fear  in  a  case,  however  severe,  of 
rheumatic  pericarditis.  With  these  precautions  the 
local  use  of  ice,  far  from  depressing  the  heart,  has 
actually  a  tonic  action.  The  feeble  and  diffused 
impulse  of  the  left  ventricle  becomes  localised  and 
stronger  ;  this  effect  is  often  very  noticeable  after  the 
icebag  has  been  used  continuously  for  some  days. 
The  friction-sound  soon  becomes  less  harsh  and  is 
heard  over  a  smaller  area  of  the  precordium.  This 
is  not  due  to  increased  exudation,  for  the  area  of 
precordial  dullness  tends  to  diminish.  If  at  the  same 
time  large  doses  of  sodium  salicylate  and  bicarbonate 
are  being  administered,  the  improvement  may  be 
very  rapid,  and  the  diminution  of  the  dullness 
remarkable.  It  must  be  remembered  that  in  rheu- 
matic pericarditis  the  effusion  of  fluid  into  the  peri- 
cardial sac  is  only  a  minor  factor  in  the  increase  of 
the  dullness ;  this  is  mainly  caused  by  dilatation  of 
the  heart.  It  is  necessary  to  insist  on  this  fact,  for  it 
is  not  yet  generally  recognised.  Rheumatic  dilatation 
of  the  heart  without  any  pericarditis  may  give  rise  to 
an  outline  of  precordial  dullness,  which  is  practically  a 
triangle  with  curved  sides  and  with  its  apex  upwards. 
When  pericarditis  is  present  also,  a  moderate  amount 


I.]  PHYSICAL  SIGNS  27 

of  pericardial  effusion  tends  to  accumulate  behind  the 
dilated  heart  in  the  recumbent  position,  and  does  not 
much  influence  the  shape  of  the  dullness.  The 
greatest  effect  of  a  moderate  pericardial  effusion  on 
the  dullness  is  produced  in  the  second  left  intercostal 
space,  in  which  a  definite  lateral  increase  of  the  dull- 
ness suggests  strongly  the  existence  of  fluid  in  the 
pericardial  sac.  A  large  pericardial  effusion  will  no 
doubt  extend  the  cardiac  dullness  further  in  all 
directions,  but  it  remains  true  that  in  rheumatic 
pericarditis  the  chief  factor  in  the  enlargement  of  the 
dullness  is  dilatation  of  the  heart. 

The  outline  of  the  precordial  dullness  on  the  right 
side  is  mainly  indicative  of  the  state  of  distension  of 
the  right  auricle.  This  statement  also  needs  to  be 
specially  insisted  on,  both  on  account  of  its  value  as 
a  suggestion  for  treatment  and  because  it  is  as  yet 
by  no  means  universally  acknowledged  that  the  con- 
dition of  the  right  auricle  can  be  determined  by  care- 
ful percussion,  its  enlargement  in  disease  of  the  lungs 
or  left  heart  watched  and  recorded,  and  its  diminu- 
tion after  leeches  or  venesection  easily  appreciated. 
In  the  normal  heart  the  dullness  of  the  right  auricle 
always  extends  about  one  fingerbreadth  (rather  less 
in  a  child)  to  the  right  of  the  sternum  in  the  fourth 
intercostal  space.  This  can  easily  be  verified  by  any 
one  who  avoids  all  artificial  pleximeters  and  percusses 
with  a  light  hammerstroke,  with  the  flexed  terminal 
phalanx  of  a  finger  of  his  right  hand,  on  the  terminal 


28  CARDITIS  AND  PERICARDITIS  [lect. 

phalanx  of  a  finger  of  his  left  hand,  firmly  applied, 
taking  special  care  to  keep  the  other  phalanges  of  the 
percussed  finger  and  the  whole  of  the  rest  of  the  left 
hand  away  from  contact  with  the  thoracic  wall. 
Unless  this  precaution  be  adopted,  pulmonary  or 
gastric  resonance  is  brought  out  at  the  same  time 
as  the  truly  cardiac,  and  confuses  the  result.  Light- 
ness of  percussion-stroke  also  assists  in  obtaining  the 
true  cardiac  note,  for  though  the  right  auricle  is  over- 
lapped by  lung,  the  auricle  with  its  contained  blood 
gives  a  dull  note  which  the  thin  overlying  lung  does 
not  alter  much,  and  at  the  border  of  the  auricle  there 
is  a  definite  alteration  in  the  note  which  careful  per- 
cussion easily  elicits. 

In  the  normal  heart  it  is  usually  difficult  to  detect 
any  dullness  in  the  third  right  space,  but  it  is  always 
definite  and  considerable  in  the  fourth.  In  the  fifth 
space  the  partial  liver-dullness  complicates  the  result. 
It  is  of  the  greatest  practical  importance  that  the 
extent  of  the  dullness  in  the  fourth  right  space  should 
be  carefully  determined  in  every  examination  of  the 
heart,  and  no  such  examination  is  anything  but  falla- 
cious unless  this  point  has  been  carefully  investigated. 

In  chronic  disease  of  the  lungs  or  left  heart,  as  in 
emphysema,  and  in  mitral  stenosis,  the  right  auricle 
is  always  dilated,  and  its  dullness  may  extend  to  two 
fingerbreadths  in  the  fourth  right  space :  it  is  then 
easily  detected  in  the  third  space  also,  and  may  there 
amount  to  a  half  or  one  fingerbreadth.     In  extreme 


I.]  DISTENSION  OF  RIGHT  AURICLE  29 

cases  it  may  reach  even  three  fingerbreadths  in  the 
fourth  space,  one  and  a  half  in  the  third  and  half  a 
fingerbreadth  in  the  second. 

In  acute  pulmonary  disease,  as  in  pneumonia,  and 
in  severe  bronchitis,  an  enlargement  of  the  right 
auricle  may  be  detected,  often  on  the  third  day  of  the 
illness,  sometimes  even  on  the  second.  Acute  rheu- 
matic carditis  affects  at  first  and  chiefly  the  ventricular 
muscle,  and  causes  distinct  enlargement  of  the  cardiac 
dullness  to  the  left,  but  in  a  first  attack  it  is  difficult 
to  detect  any  affection  of  the  auricle.  But  where 
pericarditis  is  present  there  may  be  marked  increase 
of  the  auricular  dullness.  And  this  observation  is  of 
great  importance  from  the  point  of  view  of  treatment. 
For  whenever  the  right  auricle  is  acutely  distended 
there  is  hurried  breathing.  This  is  usually  the 
explanation  of  the  dyspnoea  which  is  acknowledged  to 
be  one  of  the  symptoms  of  pericarditis ;  and  this 
dyspnoea  is  a  sign  that  the  right  heart  is  overstrained. 
In  pericarditis,  then,  if  there  are  rapid  and  deep 
inspirations  and  the  dullness  of  the  right  auricle  in 
the  fourth  space  is  found  to  amount  to  two  finger- 
breadths,  the  need  for  some  removal  of  blood  is 
evident.  Sometimes  leeches  applied  over  the  lower 
ribs  on  the  right  side  will  suffice,  but  in  a  severe  attack 
in  a  robust  subject  venesection  may  be  highly  advisable. 
I  have  seen  it  give  very  great  relief  The  same  is 
true  in  the  acute  distension  of  the  right  auricle  in 
pneumonia,     in     acute    exacerbations      of     chronic 


30  CARDITIS  AND  PERICARDITIS  [lect. 

bronchitis,  and  often  in  the  later  stages  of  mitral 
stenosis.  Dyspnoea  and  the  physical  evidence  of 
dilated  right  auricle  are  the  indications  for  bleeding, 
which  in  these  circumstances  is  a  remedy  of  priceless 
value,  capable  of  giving  immediate  relief  impossible 
by  any  other  means. 

The  first  step,  then,  in  the  local  treatment  of  rheu- 
matic pericarditis  is  the  accurate  determination  of  the 
amount  of  dullness  in  the  fourth  right  interspace,  and 
the  relief  of  a  distended  right  auricle  by  leeches,  or  in 
an  adult  by  a  venesection  removing  from  4  to  8  oz. 
of  blood.  It  may  be  well  to  follow  this  by  cardiac 
stimulation  by  means  of  a  hypodermic  injection  of 
strychnine.  Two  minims  of  the  official  solution  may 
be  used  for  an  adult,  I  or  i  minim  for  a  child.  The 
injection  may  be  repeated  after  three  hours.  Mean- 
while, at  least  two  hot-water  bottles  should  be  placed 
in  the  bed  so  as  to  make  the  patient's  lower  limbs 
thoroughly  warm.  When  this  has  been  accomplished 
(and  not  before),  an  icebag  large  enough  to  cover  the 
whole  precordial  region  and  about  half  filled  with 
small  lumps  and  fragments  of  ice  should  be  gently 
laid  over  the  heart  as  the  patient  lies  on  his  back.  If 
there  is  much  tenderness  the  icebag  may  be  at  first 
suspended  so  as  only  just  to  touch  the  skin,  but  the 
anodyne  effect  of  the  cold  will  soon  allow  of  its  more 
thorough  application.  The  icebag  will  not  by  its 
weight  increase  the  difficulty  of  breathing  if  the  right 
auricle  has  been  first  relieved. 


I.]  USE  OF  THE  ICEBAG  31 

The  patient  soon  recognises  the  beneficial  in- 
fluence of  the  ice.  Even  young  children,  after  the 
first  few  minutes,  easily  become  accustomed  to  the 
cold,  and  will  not  consent  to  its  removal.  When  it 
has  been  removed  for  an  interval  they  will  some- 
times ask  that  it  may  be  reapplied.  A  girl  of 
1 1  under  my  care  at  the  Hospital  for  Sick 
Children  said,  when  the  nurse  removed  the  icebag 
for  a  fresh  supply  of  ice,  "  May  I  have  my  icebag 
back  again  ? "  When  asked  why  she  wished  to 
have  it,  she  replied,  "  Because  it  eases  the  pain." 
A  boy  of  7  at  St  Mary's  refused  to  allow  his  icebag 
to  be  taken  away.  To  the  inquiry,  "  Why  not  ? " 
he  answered,  "  Because  I  like  it."  To  the  further 
inquiry,  "  Why  do  you  like  it  ? "  he  replied,  em- 
phatically, "  Because  I  do!' 

The  chief  difficulty  about  the  application  of  the 
icebag  is  to  secure  it  from  shifting  its  position  when 
the  patient  turns  in  bed.  This  may  be  accomplished 
by  passing  the  screw-top  of  the  icebag  through  a  hole 
in  a  binder  which  is  passed  loosely  round  the  chest 
and  secured  by  safety-pins.  Sometimes  it  may  be 
desirable  to  prevent  its  slipping  downwards  by  secur- 
ing it  by  a  light  bandage  from  behind  the  patient's 
neck.  An  excellent  method  used  at  the  Hospital  for 
Sick  Children  is  by  a  vest  made  of  domett,  with  arm- 
holes  and  a  third  hole  over  the  cardiac  region,  and 
fastened  round  the  neck  with  a  tape,  and  below  the 
icebag  by  a  safety-pin. 


32  CARDITIS  AND  PERICARDITIS  [lect. 

The  outline  of  the  precordial  dullness  should  be 
marked  on  the  skin  in  blue  for  the  guidance  of  the 
nurse.  The  icebag  will  require  to  be  refilled  about 
every  hour  and  a  half,  the  hot-water  bottles  every 
three  hours. 

It  is  well  to  have  a  second  icebag  in  use,  so  that  it 
can  be  filled  and  applied  as  soon  as  the  first  is 
removed.  In  filling  the  icebag,  be  careful  to  press 
out  the  air  as  much  as  possible  before  screwing  on  the 
top.  The  hot-water  bottles  should  not  all  be  removed 
from  the  bed  at  the  same  time,  unless  others  are  at 
once  substituted.  The  patient's  temperature  should 
be  taken  every  two  hours,  also  his  pulse-rate  and 
respiration-rate,  and  the  result  recorded  on  a  chart. 
The  nurse  must  see  that  the  icebag  does  not  leak, 
that  its  top  is  firmly  screwed  down  to  the  "  washer," 
and  that  it  is  surrounded  by  cotton-wool  or  a  soft 
towel  to  absorb  the  moisture  from  the  air  which  tends 
to  condense  on  its  surface.  Nothing  should  inter- 
vene between  the  icebag  and  the  patient's  skin. 

When  the  nursing  can  be  thoroughly  trusted,  as  in 
a  hospital,  the  icebag  may  often,  with  great  benefit  to 
the  patient,  be  applied  continuously  for  many  days, 
provided  that  the  condition  of  the  right  auricle  be 
carefully  watched,  and  the  lower  limbs  be  kept 
thoroughly  warm.  Occasionally  it  may  be  wise  to 
remove  it  for  a  few  hours  during  the  night,  especially 
between  midnight  and  six  o'clock  in  the  morning.  If 
the  nurse  has  had  little  experience  of  children,  or  is 


I.]  METHOD  AND   PRECAUTIONS  38 

not  accustomed  to  the  use  of  the  icebag  as  here 
recommended,  it  will  be  safer  to  apply  it  only  during 
the  daytime.  If  no  skilled  nursing  is  available,  the 
treatment  may  still  be  used  during  the  daytime  if  the 
mother  is  intelligent  and  careful,  and  the  practitioner 
explains  to  her  the  use  of  the  clinical  thermometer, 
and  tells  her  precisely  what  to  do.  If  the  practitioner 
is  in  doubt  whether  the  icebag  ought  to  be  continued, 
let  him  order  its  removal  for  one  hour,  and  thereafter 
its  application  for  two  hours,  and  so  on. 

It  is  sometimes  possible  to  continue  the  application 
of  ice  to  the  precordial  region  even  though  the 
temperature  have  fallen  below  the  normal.  A  child 
under  my  care  at  St  Mary's  some  years  ago,  whose 
pericarditis  had  improved  under  this  treatment  was 
found  one  evening  to  have  signs  of  pneumonia  at  the 
base  of  one  lung.  Twice  before  I  had  met  with  this 
in  young  children  suffering  from  pericarditis  and 
treated  with  ice  ;  in  each  case  when  the  pneumonia 
appeared  I  removed  the  icebag  from  the  heart,  fearing 
that  it  might  be  doing  harm.  Both  patients  died. 
When  in  this  third  case  I  again  found  pneumonia 
appearing  in  a  case  of  pericarditis  treated  with  ice,  I 
determined  to  persevere  in  my  plan  of  treatment  and 
to  push  it  further.  Two  more  leeches  were  applied, 
and  a  second  icebag  was  placed  over  the  inflamed 
lung,  that  over  the  heart  being  retained.  I  should 
hardly  have  ventured  on  this  but  for  the  kind 
willingness  of  my  house-physician,  Dr  Gordon  (now 

C 


34  CARDITIS  AND  PERICARDITIS  [lect. 

medical  superintendent  of  the  City  Fever  Hospital, 
Manchester),  who  remained  by  the  child's  bedside  and 
was  able  to  keep  the  two  icebags  in  position  during 
the  whole  night,  though  the  temperature  was  at  times 
subnormal.  When  I  saw  the  child  next  morning  the 
signs  of  commencing  pneumonia  had  disappeared  and 
recovery  was  uninterrupted.  This  case  proved  to  me 
that  with  adequate  care  it  is  possible  to  use  the  ice  in 
pericarditis  v\^hen  the  temperature  is  low.  In  the 
later  stages  of  a  pneumonia,  however,  this  is  not  the 
case. 

The  treatment  of  rheumatic  pericarditis  by  large 
and  frequent  doses  of  sodium  .salicylate  and  sodium 
bicarbonate,  with  the  local  application  of  ice  over  the 
heart,  is  amply  justified  by  its  results.  Cases  treated 
without  ice,  and  with  inefficient  medication,  are  very 
apt  to  linger  in  recovery,  and  to  result  in  a  per- 
manently dilated  and  crippled  heart.  Relapse  of 
rheumatism  frequently  occurs,  and  ends  the  case  in 
a  year  or  two.  Even  apart  from  a  probable  relapse, 
the  heart  is  often  so  severely  injured  that  symptoms 
of  failure  of  the  circulation  develop  early.  Treat- 
ment of  the  kind  here  advocated  greatly  diminishes 
the  tendency  to  rheumatic  relapse ;  it  checks  the 
inflammation,  increases  the  vigour  of  the  muscular 
fibre,  and  diminishes  the  dilatation,  thus  enormously 
assisting  the  forces  that  make  for  repair.  The  practi- 
cal difference  to  the  patient  is  often  a  difference  of 
many  years  of  life. 


I.]  TREATMENT  OF  CARDITIS  85 

In  the  milder  cases  of  rheumatic  carditis,  those  in 
which  there  is  no  evidence  of  pericarditis,  similar 
treatment  (without  the  bleeding)  may  be  used  with 
great  advantage,  though  the  effect  is  less  striking. 
Since  in  every  case  of  rheumatism,  acute  or  subacute, 
there  is  dilatation  of  the  left  ventricle,  as  may  easily 
be  proved  by  careful  percussion,  it  is  clear  that  there 
is  always  some  affection  of  the  cardiac  wall,  either 
toxic  or  inflammatory.  The  cardiac  muscle  is  weak- 
ened, as  is  proved  by  the  altered  first  sound,  the 
diffused  impulse,  and  the  enfeebled  pulse-wave.  A 
murmur  indicative  of  endocarditis  may  or  may  not 
be  present.  Here,  then,  as  really  though  not  so 
forcibly  as  in  pericarditis,  there  is  a  call  for  antirheu- 
matic medication  and  for  means  of  repressing  local 
inflammation.  I  believe  that  if  this  method  of  treat- 
ment were  universally  adopted  in  the  slighter  attacks 
of  rheumatism  it  would  very  greatly  diminish  the 
number  of  cases  of  mitral  regurgitation  and  stenosis 
in  adults,  and  would  prevent  an  enormous  amount  of 
cardiac  misery. 

Stippu  rativc  P erica  rditis. 

When  we  pass  from  acute  cardiac  inflammation 
caused  by  the  rheumatic  diplococcus  to  the  inflamma- 
tion caused  by  the  pyogenetic  cocci,  we  find  condi- 
tions differing  greatly  from  the  rheumatic,  in  physical 
signs,  in  concomitants,  in  prognosis,  and  in  treatment. 
When   these   cocci,  notably  the    pneumococcus   and 


36  CARDITIS  AND  PERICARDITIS  [lect. 

streptococci,  infect  mainly  the  endocardium,  various 
types  of  malignant  endocarditis  develop.  With  these 
I  have  no  concern  in  these  lectures,  though  I  may 
mention  that  in  a  child  under  my  care,  a  fatal  heart- 
disease  which  absolutely  resisted  salicylates  was  found 
to  have  been  caused  by  an  exuberant  endocarditis 
around  the  tricuspid  orifice,  the  mitral  valve  being  quite 
healthy,  and  that  from  this  endocarditic  growth  only 
the  pneumococcus  could  be  obtained  by  culture. 

Suppurative  pericarditis  is  very  much  less  common 
than  rheumatic,  but  it  resembles  the  latter  in  mainly 
affecting  children  and  young  adults.  It  is  generally 
associated  with  suppurative  inflammation  elsewhere, 
especially  with  empyema.  The  pus  in  the  peri- 
cardium is  often  in  small  amount,  and  often  loculated 
by  adhesions ;  the  diagnosis  is  then  extremely  diffi- 
cult. For  there  is  usually  no  friction-rub  audible,  and 
in  suppurative  pericarditis  the  heart  is  little,  if  at  all, 
dilated.  The  most  trustworthy  indications  appear  to 
be  an  extension  of  dullness  in  the  second  left  space, 
and  a  rapid,  feeble  pulse,  the  heart-sounds  becoming 
feeble  and  distant.  Where  the  amount  of  pus  in  the 
pericardium  is  considerable,  as  in  a  case  of  Dr 
Cheadle's,  which  he  kindly  allowed  me  to  examine  (a 
child  with  pus  in  the  right  pleural  cavity,  who  did  not 
improve  much  after  the  empyema  had  been  drained), 
it  may  be  possible  to  ascertain  definitely  a  considerable 
extension  of  the  precordial  dullness.  In  Dr  Cheadle's 
case,  Mr   Pepper  made  an  incision    into  the  dilated 


I.]  SUPPURATIVE  PERICARDITIS  37 

pericardial  sac  and  evacuated  a  considerable  quantity 
of  pus.    The  child  lived  for  a  week  or  two  afterwards. 

Suppurative  pericarditis,  with  a  moderate  amount 
of  pus,  is  usually  mistaken  for  loculated  empyema  of 
the  left  side.  It  is  too  common  for  the  truth  to  be 
discovered  only  in  the  post-mortem  room. 

In  three  cases  in  which  I  suspected  a  small  amount 
of  pus  in  the  pericardium,  my  colleague,  Mr  Kellock, 
made  an  exploratory  incision  into  the  pericardial  sac. 
In  the  first  and  second  of  these  cases  the  diagnosis 
proved  to  be  mistaken.  In  the  third  it  was  correct, 
but  the  operation  was  useless,  for  adhesions  to  the 
ventricular  wall  forbade  further  exploration.  In  all 
three  cases  no  harm  was  done  by  the  incision,  which 
healed  by  first  intention.  In  the  autopsy  on  the  third 
case  it  was  found  that  there  were  loculi  of  pus  around 
the  base  of  the  heart,  but  that  over  the  anterior  sur- 
face of  the  ventricle  there  was  adhesion.  A  fourth 
case,  in  which  it  seemed  to  me  that  pus  in  the  peri- 
cardium was  very  probable,  and  in  which  I  was  con- 
sidering the  question  of  operation,  gradually  and 
progressively  improved,  and  finally  recovered. 


LECTURE    II 

PNEUMONIA 

The  disease  which  we  call  "pneumonia"  consists  in 
an  invasion  of  the  lungs  and  air-passages  by  the 
micrococcus  lanceolatus  or  pneumococcus,  its  rapid 
multiplication  in  this  warm  culture-chamber,  together 
with  the  efforts,  more  or  less  successful,  which  the 
human  organism  puts  forth  to  resist  the  advance  of 
the  invading  foe  and  to  destroy  it.  The  invader  often 
lies  in  wait  in  the  mouth  of  its  unsuspecting  host,  for 
it  can  be  isolated  from  the  saliva  of  many  healthy 
persons,  as  was  first  proved  by  Sternberg.  Life  to 
such  persons  is,  as  it  were,  a  feast  of  Damocles,  with 
a  sword  hanging  by  a  hair  over  their  heads.  Too 
often  the  sword  falls  and  the  feast  of  life  is  over.  A 
chill  depresses  the  vital  power  of  resistance,  and  the 
microbe  runs  riot  in  the  pulmonary  alveoli.  Or  the 
way  is  prepared  by  other  infections,  notably  by  the 
influenza  bacillus,  and  as  the  influenzal  infection  sub- 
sides the  pneumococcal  infection  develops,  and  is  then 
of  unusual  virulence. 


LECT.  II.]       A  PNEUMOCOCCAL  INVASION  39 

The  conflict  between  the  invaders  and  the  tissues 
may  begin  at  one  definite  spot,  as  is  usual  in  adults, 
or  it  may  begin  at  the  same  time  in  several  places,  as 
is  more  frequent  in  early  life.  It  tends  to  spread 
rapidly  over  a  large  area  of  pulmonary  territory, 
and  soon  becomes  a  pitched  battle,  in  which  all  the 
powers  of  the  defenders  are  sorely  taxed  to  provide 
an  adequate  resistance.  The  blood-supplies  necessary 
for  the  very  life  of  the  defenders  are  interrupted  by 
the  stagnation  in  the  lungs.  The  fight  grows  so 
intense  that  sleep  becomes  impossible,  for  all  the 
vital  energies  are  engaged.  The  invaders  do  not 
scruple  to  use  poisoned  weapons,  and  their  poisons, 
and  even  some  of  the  enemy  themselves,  make  their 
way  into  the  blood  and  poison  the  brain. 

When  the  invaders  are  comparatively  few  or  feeble, 
and  when  the  resistance  is  powerful,  the  battle,  after 
lasting  from  three  to  seven  days  or  even  longer,  ends 
in  favour  of  the  defence,  often  with  dramatic  sudden- 
ness. The  precise  explanation  of  this  remarkable 
phenomenon  is  still  unknown,  but  the  fact  is  familiar. 
For  some  reason  or  other  the  attack  has  failed,  and 
all  that  remains  for  the  exhausted  defenders  is  to 
dispose  of  their  dead  foes,  to  clear  away  the  debris  of 
the  battle,  to  cleanse  the  battle-ground,  and  to  restore 
the  status  quo.  We  have  been  taught  to  expect  this 
happy  issue  of  the  struggle  in  children  of  more  than 
2  years  of  age,  and  in  young  adults  with  healthy 
hearts,   normal  livers,  and  sound   kidne)s,  and  it  is 


40 


PNEUMONIA 


[lect. 


certainly  in  such  patients  that  the  outlook  is  niost 
hopeful.  But  the  advent  of  the  influenza  bacillus  has 
considerably  reduced  the  confidence  which  formerly 
we  felt  with  regard  to  the  issue  of  a  pneumonic  attack 
in  the  earlier  half  of  life,  and  most  of  us  have  sorrow- 
ful reminiscences  of  friends,  strong  and  healthy,  cut 
off  by  influenza-pneumonia  in  the  very  prime  of  early 
manhood. 

Often,  alas !  the  invaders  are  too  powerful  for  the 
resistance,  and  the  patient  succumbs.  In  the  first  and 
second  year  of  life,  and  again  after  35,  the  death-rate 
from  pneumonia  is  very  considerable.  Dr  Hector 
Mackenzie  says  *  that  pneumonia  "  causes  very  nearly 
as  many  deaths  as  enteric  fever,  diphtheria,  small-pox, 
measles,  and  scarlet  fever  pnt  togetherl'  and  he  quotes 
from  the  reports  of  the  Registrar-General  the  follow- 
ing figures  showing  the  annual  rate  of  mortality  from 
pneumonia  per  million  living  at  different  ages  :-^ 


All  ages  . 

. 

.   1066 

From  birth  to  5 

years 

.   3668 

5  to  10 

years 

299 

,   10  to  15 

119 

,   15  to  20 

201 

,   20  to  25 

301 

,   25  to  35 

494 

,   35  to  45 

.    833 

,   45  to  55 

1157 

,   55  to  65 

1762 

,   65  to  75 

2596 

Ov 

^er  75 

3187 

Practitioner,  1900,  p.  36. 


II.]  PNEUMONIA  A  FIGHT  FOR  LIFE  41 

He  calculates  that  in  a  population  of  30  millions 
more  than  220,000  persons  in  each  year  are  affected 
with  pneumonia,  and  nearly  32,000  annually  die  from 
this  disease.  When  the  vitality  is  feeble,  when  the 
heart,  liver,  or  kidneys  are  damaged  by  previous 
disease,  when  there  are  old  pleural  adhesions,  when 
the  lungs  are  fibroid  or  emphysematous,  when  the 
patient  is  chronically  poisoned  with  alcohol  or  tobacco, 
and  when  septic  influences  are  at  work,  there  is  but 
a  poor  chance  of  recovery.  In  many  morbid  states 
pneumonia  ends  the  scene.  Thus  it  becomes  almost 
impossible  to  construct  statistics  which  could  give  us 
accurate  information  as  to  the  ordinary  mortality  of 
pneumonia,  or  as  to  the  results,  good  or  bad,  of  any 
proposed  method  of  treatment.  But  the  outstanding 
fact  is  this — that  every  pneicuionia  is  a  fig  J  it  for  life. 
If  we  realise  this,  we  shall  never  neglect  its  earliest 
stages ;  we  shall  not  fold  our  arms  in  careless  or  un- 
observant "  expectation,"  letting  slip  our  opportu- 
nities of  helping  the  patient  in  his  struggle  until  we 
are  confronted  with  a  disaster  which  we  have  done 
nothing  to  avert.  Can  we  not  do  something  to  pre- 
vent the  loss — how  frequent  to-day  ! — of  the  most 
important  and  valued  lives,  of  fathers  and  mothers 
of  families,  of  men  and  women  in  responsible  and 
influential  positions,  whose  continued  life  and  activity 
may  be  of  tremendous  importance  to  their  relatives 
and  friends,  to  the  community  in  which  they  live, 
perhaps  even  to  the  whole  nation? 


42  PNEUMONIA  [lect. 

If  we  are  to  succeed  in  this,  it  must  be  by  the  most 
unremitting  attention,  the  most  minute  and  careful 
observation,  and  by  the  exercise  of  a  sound  judgment 
founded  upon  previous  experience.  There  is  no 
disease  which  makes  more  demands  upon  the  practi- 
tioner than  pneumonia,  there  is  none  in  which  his 
action  or  his  inaction,  his  wise  interference  or  his 
inertia,  may  more  affect  the  issue.  Some  cases  will 
no  doubt  defy  his  best  efforts,  some  would  struggle 
through  without  his  aid,  but  in  a  large  number  he 
can  afford  very  great  relief,  and  in  many  he  may 
have  the  intense  satisfaction  of  having  certainly  saved 
a  life.  But  to  accomplish  this  he  must  be  willing  to 
spare  neither  time  nor  trouble.  He  must  visit  his 
patient  at  least  twice  daily,  at  the  most  critical  times 
he  must,  if  possible,  see  him  thrice  in  the  twenty-four 
hours.  The  struggle  is  short  and  sharp.  Every 
fresh  move  of  the  enemy  must  be  at  once  detected 
and  counteracted.  The  entire  position  of  the  attack 
and  the  defence  must  be  estimated  at  every  visit,  and 
coming  dangers  must  be  anticipated  and  provided 
for. 

In  the  treatment  of  pneumonia  one  thing  is,  unfor- 
tunately, still  lacking  to  us.  We  have  no  specific 
medication.  No  drug  is  yet  known  to  us  which  has 
an  action  on  the  pneumococcus  such  as  that  which 
the  salicylates  manifest  in  rheumatic  infections,  or  that 
which  quinine  exhibits  in  overcoming  the  malarial 
haematozoa.     Yet  our  reminiscence  of  the  days  when 


II.]  THE  RIGHT  HEART  43 

rheumatism  had  to  be  treated  without  salicylates 
should  encourage  us  in  the  hope  that  some  day  we 
may  possess  a  specific  remedy.  Neither  from  serum- 
therapy  is  there  any  present  prospect  of  assistance. 
Yet  here  also  it  would  be  rash  to  predict  what  the 
future  may  have  in  store  for  us. 

But  we  have  to  consider  the  position  as  it  exists 
to-day.  If  we  cannot  overwhelm  the  foe  by  ordinary 
medication  or  by  the  subtle  influence  of  an  antitoxin, 
we  may  at  least  help  the  patient  to  fight  his  battle, 
and  in  more  ways  than  one  intervene  actively  for  his 
relief  The  problem  is  essentially  how  to  keep  him 
alive  until  the  battle  is  over.  A  prolongation  of  life 
for  forty-eight  hours  will  often  turn  a  threatening 
defeat  into  a  glorious  victory. 

I.    The  Right  Heart. 

How,  then,  does  pneumonia  tend  to  kill  ?  Usually 
by  cardiac  failure.  But  this  is  a  failure,  not  of  the 
left  side  of  the  heart,  but  of  the  right ;  not  by  syncope, 
but  by  asphyxia ;  not  through  enfeeblement  of  the 
left  ventricle,  but  through  paralysing  overdistension 
of  the  right. 

It  is  remarkable  how  little  dilatation  of  the  left 
ventricle  can  be  detected  in  pneumonia.  Of  course 
the  pulmonary  stagnation  tends  to  diminish  the 
tension  in  the  left  ventricle ;  but  if  the  pneumococcal 
toxin  were  as  injurious  to  the  ventricle  as  the  rheu- 
matic, an  increase  of  the  cardiac  dullness  to  the  left 


U  PNEUMONIA  [lect. 

would  be  unmistakable.  In  influenza  such  a  toxic 
dilatation  may  be  often  observed,  and  it  sometimes 
leads  to  fatal  syncope.  This  action  on  the  left  ventricle 
by  the  influenzal  toxin  is  probably  the  main  cause  of 
the  greater  fatality  of  pneumonia  when  following  an 
attack  of  influenza,  as  well  as  of  influenzal  broncho- 
pneumonia itself  In  influenza  the  cardiac  dullness 
may  extend  one  and  a  half  or  two  fingerbreadths  to 
the  left  of  the  nipple-line ;  in  a  pneumococcal  pneu- 
monia it  does  not  often  extend  much  beyond  the 
nipple-line,  and  even  this  moderate  increase  seems 
often  to  be  caused  by  the  distension  of  the  right  side 
of  the  heart,  for  it  may  subside  at  once  after  a  bleed- 
ing. Thus  it  seems  that  the  pneumococcus  and  its 
toxin  do  not  attack  the  ventricular  wall  so  actively  as 
the  influenza  bacillus  or  the  rheumatic  diplococcus. 

It  must  of  course  be  remembered  that  the  left 
ventricle  may  be  found  enlarged  as  the  result  of 
previous  disease,  rheumatic  or  otherwise,  as  the  effect 
of  strain  or  of  arterio-sclerosis  or  granular  kidney.  In 
any  case  it  adds  gravity  to  the  prognosis. 

But  the  right  side  of  the  heart  is  in  pneumonia 
very  soon  overburdened  by  the  pulmonary  stagna- 
tion, and  it  quickly  shows  signs  of  distress.  Within 
forty-eight  hours  from  the  onset  evidence  of  dilatation 
of  the  right  auricle  can  often  be  detected  by  percus- 
sion in  the  fourth  right  space.  Unless  means  be 
adopted  to  relieve  it,  the  right  side  becomes  increas- 
ingly embarrassed  as  the  days  of  the  terrible  pneu- 


II.]  RIGHT-HEART  MISERY  45 

monia-week  pass  by.  The  normal  fingerbreadth  of 
dullness  in  the  fourth  right  space  becomes  doubled, 
perhaps  more  than  doubled,  and  dullness  may  be 
found  in  the  third  space  as  well.  The  first  symptom 
caused  by  the  distension  of  the  auricle  is  an  increase 
in  the  rate  of  the  respiration.  At  a  later  stage  this 
is  accompanied  by  lividity  of  the  lips  and  cheeks,  with 
pallor.  This  lividity  may  increase  to  a  general  cyan- 
osis due  largely  to  the  interference  with  oxygenation 
in  the  lungs.  As  the  tension  in  the  right  heart  in- 
creases, the  patient  feels  much  oppression  and  distress, 
and  often  becomes  very  restless,  seeking  ease  in  change 
of  position  and  not  finding  it.  This  right-heart  misery 
may  be  quickly  relieved  by  a  little  loss  of  blood.  In 
an  early  stage  from  three  to  six  leeches  will  at  once 
remove  the  distress,  and  the  dullness  of  the  right 
auricle  rapidly  diminishes  to  the  normal  fingerbreadth. 
The  relief  will  usually  last  for  forty-eight  hours,  after 
which  time  renewed  distension  of  the  right  side  may 
again  demand  relief  In  a  severe  case  it  may  be  advis- 
able to  use  leeches  three  times  during  the  week  but  in 
many  cases  two  applications  of  leeches  will  suffice  to 
keep  the  right  auricle  from  paralysing  overdistension 
until  the  crisis 

An  old  lady  of  73,  the  mother  of  a  Fellow  of  the 
Royal  College  of  Surgeons,  was  seized  with  pneu- 
monia of  moderate  severity.  At  first  all  went  fairly 
well,  but  on  the  fifth  day  her  pulse  began  to  show 
intermissions,  the  lips  became  blue,  the  respiration- 


46  PNEUMONIA  [lect. 

rate  rose  to  40,  and  she  became  very  restless.  The 
next  morning  (sixth  day)  she  told  me  that  she  was 
very  ill  and  was  going  to  die.  I  found  that  the  right 
auricle  extended  two  fingerbreadths  in  the  fourth 
right  space.  Her  son  at  once  saw  the  necessity  for 
some  removal  of  blood,  in  spite  of  her  advanced  age, 
and  eight  leeches  were  applied  over  the  lower  right 
ribs.  In  the  evening  she  was  again  quite  cheerful, 
and  I  found  that  the  dullness  of  the  right  auricle  had 
nearly  returned  to  the  normal  fingerbreadth.  Three 
days  later  she  again  had  a  very  restless  night  and 
said  that  she  was  going  to  die.  Again  I  found  the 
right  auricle  dilated.  Three  leeches  only  were  enough 
to  give  relief  on  this  occasion.  Next  day  she  was 
out  of  danger,  and  recovery  followed.  Some  weeks 
later  I  chanced  to  meet  her  in  the  street,  when  she 
volunteered  the  remark,  "  You  know,  doctor,  tJiose 
blackies  did  me  good  !  " 

By  way  of  contrast,  let  me  mention  the  case  of  a 
much  younger  lady  whom  I  saw  in  consultation  and 
found  to  be  suffering  from  pneumonia.  No  attention 
had  been  paid  to  the  right  heart ;  it  was  much  dilated, 
and  the  condition  of  the  patient  critical.  Feeling  sure 
that  it  would  be  useless  to  propose  a  venesection,  I 
requested  the  practitioner  in  charge  to  apply  leeches. 
His  reply  was  that  he  would  "see  if  any  could  be 
obtained  in  the  neighbourhood."     The  patient  died. 

If  the  early  leeching  be  omitted  the  right  auricle 
may  become,  as   in   this   case,  much  distended,  and 


II.]  RELIEF  BY  BLOOD-LETTING  47 

right-heart  misery  may  be  marked.  In  this  condition 
it  is  better  to  have  recourse  to  venesection  and  to 
remove  6  oz.  or  8  oz.  of  blood.  A  larger  quantity 
should  be  taken  when  the  dilatation  of  the  right  heart 
is  great,  the  pulmonary  consolidation  extensive,  and 
moist  rales  heard  over  the  rest  of  the  lungs.  In  such 
circumstances  i8  oz.  or  20  oz.  of  blood  must  be  taken 
if  the  patient  is  to  have  a  chance  of  life.  I  have 
seen  life  saved  even  at  this  stage  by  a  venesection  to 
18  oz.  The  blood  obtained  by  venesection  is  often 
very  dark  in  colour,  and  it  sometimes  spurts  out  as  if 
from  an  artery  when  a  vein  is  opened,  showing  the 
increased  intravenous  tension,  and  proving  the  need 
for  relief  of  the  intra-auricular  tension. 

In  using  the  amount  of  dullness  in  the  fourth  right 
space  as  a  guide  when  considering  whether  or  not  to 
bleed,  it  is  necessary  to  be  careful  not  to  overestimate 
the  size  of  the  auricle,  owing  to  pulmonary  consolida- 
tion in  its  immediate  neighbourhood  or  to  pleural 
effusion,  and,  on  the  other  hand,  not  to  underestimate 
it  through  a  local  hyper-resonance  of  lung  caused  by 
compensatory  hyper-distension  of  parts  of  lung  not 
yet  implicated  in  the  inflammatory  process.  Of  the 
two  errors,  probably  the  latter  is  the  more  serious, 
for  it  may  tend  to  postpone  a  relief  which  the  heart 
greatly  needs.  In  case  of  doubt  the  practitioner  will 
be  wise  to  decide  for  the  leeches ;  they  can  hardly  do 
any  harm  and  they  may  do  much  good. 

The  total  amount  of  blood  removed  by  even  three 


48  •         PNEUMONIA  [lect. 

applications  of  leeches  or  by  a  moderate  venesection 
is  really  quite  small.  The  plan  here  recommended 
is  something  very  different  from  the  excessive  bleed- 
ings of  former  days,  and  the  purpose  is  different.  It 
is  not  with  the  idea  of  controlling  an  inflammatory 
process,  but  with  the  intention  of  giving  relief  to  an 
overstrained  right  heart. 

The  repeated  bleeding  of  cases  of  pneumonia 
advocated  and  practised  sixty  years  ago  was  based 
on  theoretical  considerations.  But  it  would  hardly 
have  been  continued  so  persistently  if  some  benefit 
had  not  been  observed  to  follow  its  first  employment 
in  most  cases.  Doubtless,  this  benefit  was  the  relief 
of  the  right  heart  unintentionally  produced  and  the 
consequent  diminution  of  dyspnoea  and  restlessness. 

The  most  important  part,  then,  of  the  treatment  of 
pneumonia  is  to  keep  a  constant  watch  07t  the  cofidition 
of  the  right  heart,  and  to  prevent  its  overdistension  by 
the  ti))iely  I'emoval  of  a  small  quantity  of  blood.  This 
indication  is,  unfortunately,  too  generally  neglected. 
The  omission  is  probably  responsible  for  a  large  part 
of  the  mortality  from  pneumonia.  If  a  patient  suffer- 
ing from  distension  of  the  urinar}-  bladder  came  under 
the  care  of  a  medical  man,  he  would  be  at  once 
relieved.  But  if  it  be  the  patient's  right  heart  that  is 
distended,  a  condition  causing  equal  misery,  equally 
dangerous,  equally  capable  of  being  diagnosed,  and 
equally  easy  of  relief,  the  patient  will  probably  be 
left  to  take  his  chance,  because  the  practitioner's  per- 


11.]  DIET  49 

cussion  is  inadequate  and  bleeding  is  out  of  fashion. 
No  improvement  in  the  physical  examination  of 
patients  is  more  needed  than  an  improved  percussion 
of  the  heart ;  no  reform  in  therapeutics  is  more 
urgent  than  a  general  adoption  of  the  practice  of 
moderate  blood-letting  in  some  diseases  of  the  heart 
and  of  the  lungs, 

2.  Diet. 

It  is  obvious  that  the  diet  during  an  attack  of 
pneumonia  must  be  such  as  can  be  taken  without 
effort,  such  as  can  be  easily  digested,  and  such  as 
shall  readily  be  assimilated.  Milk  fulfils  all  these 
indications ;  it  has  also  somewhat  of  a  diuretic  influ- 
ence, and  thereby  will  assist  the  elimination  of  toxin. 

But  there  is  one  point  which  needs  consideration. 
The  introduction  of  a  fluid  nutriment  in  large  quantities 
will  tend  to  increase  the  quantity  of  fluid  passing 
through  the  right  heart,  and  this  is  a  matter  of  import- 
ance when  that  organ  is  already  overstrained.  For 
the  first  two  or  three  days  of  the  disease  milk  alone, 
in  quantities  of  3  or  4  pints  daily  for  an  adult,  should 
be  given.  But  when  the  right  auricle  is  becoming 
dilated  it  is  wise  to  administer  small  quantities  of  a 
highly  concentrated  and  predigested  nutriment.  A 
useful  resource  at  this  time  may  be  found  in  "  malted 
milk,"  a  dry  powder  one-half  of  which  consists  of  desic- 
cated milk,  the  other  half  of  malted  wheat  and  malted 
barley,  with  a  little  sodium  and  potassium  bicarbonate. 

D 


50  PNEUMONIA  [lect. 

Half  an  ounce  of  this  dissolved  in  2  oz.  of  milk  may 
be  given  every  hour  while  the  patient  is  awake ;  for 
a  child  the  amount  may  be  2  teaspoonfuls  in  i  oz. 
of  milk.  Thirst  will  probably  not  be  felt  for  a  day  or 
two,  and  it  may  then  be  satisfied  in  another  way,  for 
as  soon  as  the  first  leeches  have  relieved  the  right 
heart,  it  is  possible  to  administer  without  harm  con- 
siderable quantities  of  water.  As  much  as  4  pints  of 
water  may  be  given  in  divided  doses  of  half  a  pint 
every  three  hours  during  the  day  following  the  relief 
by  leeches  or  venesection.  This  not  only  satisfies 
thirst  but  it  helps  to  wash  out  the  pneumococcal  toxin, 
and  thus  is  of  great  value.  I  have  seen  this  measure 
produce  a  most  marked  effect  in  removing  the  delirium 
in  a  severe  case  of  typhoid,  and  it  has  a  similar 
influence  in  pneumonia. 

3.  Sleep. 

In  pneumonia  sleep  may  be  disturbed  from  the  first 
by  pain  in  the  side,  afterwards  by  continued  pain,  by 
dyspnoea  and  restlessness,  by  fever  and  rapid  pulse, 
finally  by  cerebral  congestion,  and  even  by  pneumo- 
coccal invasion  of  the  meninges.  Yet  the  refresh- 
ment of  sleep  is  most  important  if  the  patient  is 
to  fight  a  winning  battle,  and  the  lack  of  it  sadly 
diminishes  his  energy  and  power  of  resistance.  Every 
nighfs  sleep  is  of  importance.  Restless  and  disturbed 
nights  in  the  early  part  of  the  attack  are  often  re- 
garded too  lightly  by  the  practitioner  in  attendance. 


II.]  SLEEP  51 

When  the  fourth  or  fifth  comes,  and  the  need  for  sleep 
is  urgent  and  distressing,  he  dares  not  administer 
hypnotics  because  of  the  danger  of  inducing  a  fatal 
coma.  Whenever  a  medical  man  is  called  in  at  the 
onset  of  an  attack  of  pneumonia,  let  him  never  forget 
to  make  sure  that  the  patient  sleeps  during  the  first 
three  nights  of  his  illness.  Whatever  other  treatment 
he  may  adopt,  or  refrain  from  adopting,  let  him  take 
measures  to  diminish  pain  and  to  secure  sleep.  If  there 
is  pain  which  cannot  be  otherwise  relieved,  morphine 
by  injection  under  the  skin  is  necessary,  and  at  this 
early  stage  is  perfectly  safe.  If  pain  is  slight  or  has 
been  relieved,  a  dose  of  bromide  and  chloralamide,  or 
of  trional,  or  a  Dover's  powder,  with  hot  brandy  and 
water,  will  sufifice.  But  pain  must  be  relieved  and 
sleep  secured. 

When  the  right  heart  is  overstrained  the  procuring 
of  sleep  is  a  difficult  and  anxious  question.  When 
dyspnoea  becomes  distressing  it  is  almost  impossible 
for  the  patient  to  sleep  ;  all  his  energies  are  needed 
for  the  maintenance  of  the  respiratory  function.  Mor- 
phine given  at  this  time  diminishes  the  activity  of  the 
respiratory  centre,  on  the  energy  of  which  his  life  de- 
pends, and  may  induce  a  coma  which  will  end  in  death. 
The  way  out  of  this  dilemma  is  found  in  a  relief  of 
the  right  heart. 

After  leeches  or  venesection  the  urgency  of  the 
dyspnoea  subsides,  the  cyanosis  diminishes,  comfort  is 
restored,  and  the  wearied  patient  may  fall  asleep  with- 


52  PNEUMONIA  [lect. 

out  any  narcotics.  This  effect  is  often  most  marked 
and  most  encouraging.  But,  if  necessary,  a  small  dose 
even  of  morphine  may  now  be  given  with  safety,  or 
other  hypnotics  if  pain  be  absent.  The  double  effect 
of  the  relief  to  the  heart  and  the  rest  to  the  nervous 
system  gives  the  patient  an  enormous  advantage  in  the 
struggle  which  still  lies  before  him.  Even  at  a  late 
stage  of  a  severe  case  morphine  may  sometimes  be 
safely  given,  provided  that  the  right  heart  has  been 
relieved  by  a  venesection  an  hour  or  two  previously. 
But  where  a  careful  watch  has  been  kept  on  the  right 
heart,  and  it  has  been  duly  relieved  by  leeches,  and 
at  the  same  time  a  vigorous  attack  has  been  made 
on  the  inflamed  areas  in  the  lungs  by  the  free  use 
of  ice  externally,  morphine  is  hardly  ever  necessary, 
unless  the  pleura  is  severely  involved  and  an  empyema 
is  forming. 

4.  Cardiac  Tonics. 

Medicines  which  assist  the  heart  to  maintain  the  cir- 
culation are  often  of  much  service  in  the  later  days  of  a 
pneumonia.  It  is  generally  advisable  to  begin  the  use 
of  these  about  the  third  or  fourth  day  of  the  disease, 
and  they  ought  to  be  given,  if  at  all,  somewhat  freely. 

Of  these  drugs,  strychnine  is  probably  the  most 
useful.  It  should  be  given  by  subcutaneous  injection. 
Half  to  one  minim  of  the  official  solution  twice  daily 
should  be  the  initial  dose  for  a  child  ;  for  an  adult,  2 
minims  morning  and  evening  at  first,  increasing  to  5 


II.]  CARDIAC  TONICS  53 

minims  if  necessary.  Even  larger  or  more  frequent 
doses  may  be  given  with  advantage  in  influenza  with 
dilatation  of  the  left  ventricle. 

Atropine  by  subcutaneous  injection  is  also  very 
serviceable  in  children,  but  not  so  useful  for  adults, 
because  they  suffer  much  more  than  children  from  the 
dryness  of  throat  and  other  unpleasant  effects  of  bella- 
donna. In  children  large  doses  of  this  drug  will  cause 
chiefly  flushing  of  skin,  which  is  of  no  importance. 
If  the  dose  be  further  increased  there  may  be  dilata- 
tion of  pupil,  some  mental  excitement  and  restlessness, 
in  some  cases  diarrhoea.  The  subcutaneous  injection 
of  I  minim  of  the  liquor  atropinae  at  first  twice  daily, 
afterwards  every  four  hours,  is  often  of  the  greatest 
possible  service  in  the  cardiac  failure  of  diphtherial 
paralysis.  I  have  used  it  for  many  years,  and  am  con- 
vinced that  it  has  often  saved  life.  But  it  must  be 
given  freely,  and  one  must  not  be  afraid  of  a  little 
delirium.  Small  doses  are  useless  in  a  condition  like 
this.  Strychnine  may  be  given  with  advantage  at  the 
same  time,  but  I  am  sure  that  the  atropine  is  the  more 
useful.  In  the  paroxysmal  dyspnoea  of  mitral  stenosis, 
with  rapidly  -  increasing  breathlessness,  pallor,  and 
sometimes  evidence  of  dilatation  of  the  right  auricle,  a 
subcutaneous  injection  of  4  minims  of  liquor  atropinae 
will  often  cut  short  the  attack  in  a  few  minutes,  and 
in  children  and  adolescents  will  cause,  as  a  rule,  no 
unpleasant  consequences.  The  same  treatment  is 
sometimes  effectual  in  older  patients,  but  in  them  the 


54  PNEUMONIA  [lect. 

after-results  of  belladonna  are  much  more  trouble- 
some. 

In  the  pneumonia  of  children  belladonna  has  been 
strongly  recommended  by  Dr  Coutts,  and  Dr  Eustace 
Smith  has  told  me  of  an  apparently  hopeless  case  of 
pneumonia  in  a  child  in  which  recovery  followed  the 
free  use  of  belladonna,  the  child  being  delirious  for 
three  days.  The  tendency  of  the  drug  to  cause  delirium 
is  a  great  disadvantage  in  using  it  for  pneumonia, 
which  itself  is  very  prone  to  cause  delirium.  On  the 
whole,  it  is  a  remedy  much  more  useful  for  children 
than  for  adults. 

Oxygen  by  inhalation  assists  the  aeration  of  blood 
in  the  lungs,  and  thus  improves  the  quality  of  the 
blood  supplied  to  the  cardiac  muscle.  It  is,  therefore, 
truly  a  cardiac  tonic.  Its  use  should  be  begun  as 
soon  as  cyanosis  is  definite,  and  should  be  continued 
for  five  minutes  every  hour,  whether  the  patient  is 
awake  or  asleep.  It  can  be  given  without  disturbing 
him  in  the  least.  Oxygen  is  certainly  a  most  valuable 
remedy,  and  ranks  with  strychnine  in  the  treatment 
of  pneumonia.  But  neither  strychnine  nor  oxygen, 
nor  both  together,  will  often  save  life  if  the  right 
auricle  be  not  relieved.  After  a  bleeding  they  arc 
powerful  remedies ;  without  removal  of  blood  they 
often  fail,  and  almost  necessarily.  It  is  good  to 
maintain  the  strength  of  the  cardiac  muscle  ;  it  is 
still  better  to  diminish  its  labour.  It  is  best  to  do 
both. 


II.]  ICE  55 

Digitalis  will  not  always  reduce  the  frequency  of 
the  pulse  in  pneumonia,  especially  when  the  tempera- 
ture is  high.  It  is  most  likely  to  be  of  service  after 
relief  of  the  right  heart,  when  the  fever  is  moderate 
and  the  pulse  still  remains  weak  and  frequent. 

Ammonium  carbonate  may  be  given  when  there 
is  evidence  of  much  secretion  in  the  bronchial  tubes. 

Alcohol,  though  called  a  "stimulant,"  has  not  much 
title  to  be  considered  a  cardiac  tonic.  It  is  essentially 
a  vasomotor  depressant,  and  as  such  may  help  the 
heart  indirectly  when  the  tension  is  high.  There  is 
also  sometimes  a  temporary  increase  in  the  strength 
of  the  pulse  after  the  administration  of  a  moderate 
dose,  probably  due  to  increased  blood-supply  to  the 
cardiac  muscle,  through  relaxation  of  coronary  arte- 
rioles. It  is  therefore  possible  that  repeated  small 
doses  may  be  of  service  in  pneumonia,  but  the  large 
doses  sometimes  advised  are  likely  to  do  more  harm 
than  good.  To  imagine  that  brandy  can  "  support " 
the  heart  when  the  right  side  is  becoming  paralysed 
from  overdistension  is  absurd.  In  such  a  case  the 
only  satisfactory  cardiac  tonic  is  a  venesection. 

5.  Ice. 

In  pneumonia  the  application  of  ice  to  the  wall  of 
the  chest  is  as  helpful  as  it  is  in  pericarditis,  but  it 
must  be  used  much  more  freely.  A  single  icebag 
will  cover  the  whole  anterior  surface  of  the  heart,  but 
the  lung  is  a  much  larger  organ,  and  for  the  efficient 


56  PNEUMONIA  [lect. 

treatment  of  an  inflamed  lung  at  least  two  icebags, 
often  three,  are  required.  If  both  lungs  are  attacked 
four  icebags  may  be  necessary  in  the  case  of  an 
adult.  It  is,  therefore,  all  the  more  important  to  keep 
in  mind  the  two  precautions  which  I  have  already 
mentioned  :  the  feet  and  lower  limbs  must  be  kept 
continuously  warm  by  means  of  hot-water  bottles, 
and  the  right  heart  must  not  be  permitted  to  be 
overdistended.  The  temperature  should  be  taken 
and  recorded  every  two  hours  ;  in  the  case  of  a  young 
child  this  should  be  done  every  hour.  Of  course  the 
most  efficient  nursing  is  required  and  should  be 
provided  from  the  first. 

The  parts  of  the  lung  which  are  inflamed  must  be 
determined  by  careful  percussion,  and  outlined  on  the 
chest  with  a  blue  pencil.  The  icebags  must  be  care- 
fully kept  in  contact  with  the  skin  over  the  areas 
thus  determined,  by  passing  their  screw-tops  through 
holes  in  a  binder  loosely  fastened  round  the  chest,  or 
a  vest  may  be  cut  out  of  domett  as  above  advised  in 
pericarditis.  Special  care  must  be  taken  that  there 
is  no  leaking,  also  that  they  are  surrounded  by 
cotton-wool  or  a  soft  towel,  and  a  pretty  thick  padding 
of  such  material  is  needed  when  the  patient  has  to 
lie  on  the  icebags  applied  to  his  back.  This  is  really 
the  greatest  difficulty  in  the  use  of  icebags  in 
pneumonia ;  the  patient  hardly  ever  dislikes  the 
cold,  but  the  pressure  of  the  small  lumps  of  ice  on 
the  back  as  the  patient  lies  upon  the  bags  sometimes 


II.]  PHYSICAL  EXAMINATION  57 

taxes  the  skill  of  the  nurse  to  arrange  matters  com- 
fortably. 

At  least  once  daily,  preferably  twice,  the  practitioner 
must  percuss  the  whole  of  both  lungs  as  well  as  the 
heart.  This  must  be  done -systematically  and  with 
care.  Begin  with  the  heart  and  determine  the  limit 
of  its  dullness  to  the  left,  and  especially  its  limit  to 
the  right  in  the  fourth  and  third  intercostal  spaces. 
Notice  the  strength  of  the  impulse  of  the  left  ventricle 
and  the  force  of  the  epigastric  pulsation  of  the  right 
ventricle.  Listen  to  the  quality  of  the  first  sound, 
and  observe  the  strength,  rate,  size,  rhythm,  and 
length  of  the  pulse-wave.  Notice  whether  the  aortic 
second  sound,  and  especially  the  pulmonary  second 
sound,  is  too  loud  or  too  feeble.  Then  percuss  care- 
fully the  front  of  the  lung  and  the  upper  axilla  of 
each  side  from  above  downwards  quite  down  to  the 
anterior  base,  carefully  noting  and  marking  the  limits 
of  any  areas  of  dullness.  Listen  for  crepitant  sounds, 
especially  inspiratory  crepitation,  and  for  bronchial 
or  tubular  breathing,  but  do  not  fatigue  the  patient 
by  attempting  to  elicit  bronchophony.  All  this  can 
be  done  in  a  few  minutes.  Then  turn  the  patient 
over  on  his  right  side  and  carefully  examine  the  back 
of  the  left  lung  from  above  downwards  and  the  axillary 
region,  marking  out  all  dull  areas  as  before.  Let  the 
patient  rest  for  a  minute  or  two  on  his  back,  and 
then  turn  him  over  on  his  left  side  and  examine  in  a 
similar  manner  his  right  lung  and  right  axilla.     You 


58  PNEUMONIA  [lfxt. 

have  now  a  fairly  accurate  idea  of  the  extent  and 
distribution  of  the  areas  of  inflammation.  In  children 
these  are  almost  always  multiple  and  scattered  over 
both  lungs,  some  of  the  dull  areas  being  partly  due  to 
collapse.  But  even  in  children  the  inflammation  may 
tend  to  spread  chiefly  at  one  spot,  and  to  involve  a 
large  part  or  even  the  whole  of  one  lung,  while  the 
other  is  comparatively  little  affected.  Yet,  even  in 
such  so-called  "  lobar  "  cases  careful  percussion  almost 
always  yields  areas  of  dullness  in  the  opposite  lung. 
And  this  is  of  great  importance,  for  if  these  areas  are 
allowed  to  spread,  they  may  develop  into  such  exten- 
sive areas  of  inflammation  that  the  most  careless 
percussor  cannot  fail  to  notice  that  he  now  has  to 
deal  with  a  "  double  pneumonia." 

In  adults  the  inflammation  is  usually  more  localised 
than  in  children,  but  there  is  the  same  tendency^to 
spread.  This  extension  of  dullness  can  be  easily 
watched  by  careful  percussion  practised  daily,  and  a 
very  good  idea  of  the  intensity  and  virulence  of  the 
inflammation  may  thus  be  obtained.  This  is  requisite 
for  the  efficient  use  of  the  icebags.  It  is  impossible 
to  surround  the  whole  of  both  lungs  with  ice ;  it  is 
therefore  necessary  to  determine  where  the  lung  is 
inflamed,  and  in  which  direction  the  inflammation  is 
spreading,  and  to  apply  the  ice  over  precisely  those 
areas.  Place  the  first  icebag  on  the  largest  dull 
portion  of  lung,  and  apply  a  second  bag  behind  or  in 
front,  so  as  to  enclose  the  inflamed  area.     These  ice 


II.]         EFFECTS  OF  THE  ICE-TREATMENT  59 

applications  are  generally  very  pleasant  to  the  patient. 
An  old  lady  of  62,  after  a  few  hours'  trial  of  an  icebag, 
declared  it  to  be  "  delicious."  A  young  lady  of  19 
said  that  it  was  "  lovely,"  and  when  asked  whether 
she  wished  it  continued,  replied  with  emphasis,  "  Oh, 
rather  !  yes  !  "  Nor  is  there  usually  any  difficulty  in 
persuading  the  patients  to  try  this  method,  for  they 
have  generally  already  tried  hot  applications,  and 
have  found  little  or  no  relief.  With  a  temperature 
of  104°  it  is  easy  to  understand  that  cooling  means 
comfort.  The  difficulty  is  not  with  the  patients,  but 
in  overcoming  the  prejudices  of  the  patients'  friends. 

At  the  next  visit  of  the  practitioner  after  the 
application  of  the  icebags  let  him  remove  them,  and 
carefully  percuss  again  the  areas  to  which  they  have 
been  applied.  He  will  generally  find  that  they  are 
less  dull  than  on  the  previous  occasion,  and  that  the 
air  enters  them  in  inspiration  better  than  before.  He 
may  even  find  that  the  dull  area  is  somewhat  smaller. 
Encouraged  by  this  observation  he  will  replace  the 
icebags,  and  will  proceed  to  attack  any  other  dull 
area  that  he  can  find  by  means  of  a  third  icebag.  At 
the  next  visit  he  may  find  that  the  areas  attacked 
show  signs  of  further  improvement,  or,  at  all  events, 
have  not  extended.  But  the  inflammation  may  at 
the  same  time  be  spreading  elsewhere ;  new  spots  of 
dullness  may  have  appeared,  or  dull  areas  formerly 
small  may  be  rapidly  extending.  This  should  be 
suspected  especially  when  the  temperature  continues 


60  PNEUMONIA  [lect. 

high  in  spite  of  the  application  of  the  ice,  or  when 
after  falHng  it  again  rises.  Then  let  the  practitioner 
make  diligent  search  for  fresh  and  extending  patches 
of  dullness ;  he  will  often  find  them,  perhaps  in  the 
lung  he  had  thought  unaffected.  Care  in  this  matter 
is  of  the  greatest  importance  to  the  patient,  for  if 
such  patches  be  detected  in  their  earliest  stage,  it  is 
remarkable  how  quickly  they  will  yield  to  the  local 
influence  of  the  ice,  but  if  they  are  overlooked  or 
neglected  they  often  increase  rapidly,  and  may  become 
extremely  serious.  It  is  specially  desirable  to  have 
the  ice  over  the  spreading  edges  of  the  inflamed  areas 
as  far  as  this  can  be  managed.  It  is  often  necessary 
to  shift  their  position,  more  or  less,  at  least  twice 
daily,  sometimes  more  frequently.  It  may  be  needful 
at  every  visit  to  give  fresh  directions  to  the  nurse  as 
to  the  exact  areas  to  which  the  ice  is  to  be  applied. 
This  is  one  reason  why  in  pneumonia  two  visits  daily 
are  essential,  three  sometimes  desirable.  The  pro- 
gress of  the  conflict  must  be  watched  over  the  whole 
battlefield,  during  the  whole  struggle,  by  the  general 
in  command,  if  he  is  to  secure  the  victory.  The  right 
heart  and  both  lungs  must  be  most  carefully  examined 
in  detail  at  least  once  daily,  a  second  time  if  the 
strength  of  the  patient  will  allow  it.  It  may  some- 
times be  better  to  omit  a  minute  examination  at  the 
evening  visit,  but  at  the  morning  visit  the  whole 
ground  should  be  carefully  gone  over. 

Thus  far  I  have  advocated  the  use  of  the  icebag  in 


II.]  THE  PNEUMOCOCCUS  61 

pneumonia  solely  on  the  ground  of  my  own  experience 
of  its  practical  utility.  But  something  may  be  said  in 
its  favour  from  the  standpoint  of  bacteriological 
science.  For  bacteriologists  find  that  the  pneumo- 
coccus  is  remarkably  susceptible  to  changes  in  its 
environment,  and  in  particular  to  changes  of  tempera- 
ture. Slight  alterations  in  the  composition  of  the 
culture-media  will  affect  its  growth,  so  that  it  is  very 
difficult  to  cultivate.  Dr  Eyre,  who  with  the  late  Dr 
Washbourn  has  specially  studied  this  organism,  tells 
us*  that  it  is  "  extremely  susceptible  to  variations  of 
temperature."  He  adds  that  "  the  range  of  tempera- 
ture enjoyed  by  the  pneumococcus  is  limited  to  about 
14°,  and  is  bounded  by  28"^  C.  on  the  one  hand,  below 
which  n®  growth  takes  place,  and  by  42°  C.  on  the 
other.  The  optimum  temperature  is  undoubtedly  37.5° 
C."  It  is,  therefore,  not  unlikely  that  persistent  local 
reduction  of  temperature  of  a  pneumonic  lung,  even 
though  of  moderate  amount,  may  exercise  a  definite 
inhibitory  influence  on  the  rate  of  multiplication  of 
the  developing  pneumococci.  Fortunately  this  is 
specially  likely  to  be  true  in  the  worst  cases  of  the 
disease,  for  Dr  Washbournf  showed  from  his  experi- 
ments that  the  greater  the  virulence  the  pneumococcus 
is  found  to  possess,  the  more  marked  is  its  susceptibility 
to  surrounding  influences,  and  the  more  difficult  it  is 
to  cultivate.     Less  virulent  "  strains  "  of  this  organism 

*  Practitioner^   1900,  p.  285. 

t  Croonian  Lectures,  Lancet^  1900. 


62  PNEUMONIA  [lect. 

were  able  to  grow  at  lower  temperatures.  He  found 
that  a  pneumococGus  which  was  slightly  virulent,  and 
which  would  grow  on  artificial  media  at  a  temperature 
as  low  as  20'  C,  could  by  passages  through  animals 
be  converted  into  a  highly  virulent  type,  which  would 
not  grow  on  artificial  media  at  temperatures  below 
37°  C  If  this  is  so,  it  suggests  that  the  ice-treat- 
ment may  have  a  special  utility  in  the  worst  types  of 
pneumonia. 

It  is  difficult  to  estimate  the  amount  of  local  reduc- 
tion of  temperature  caused  by  the  persistent  application 
of  ice  over  an  inflamed  lung,  and  there  seem  to  be  no 
available  observations  on  the  comparative  rate  of 
growth  of  the  pneumococcus  at  temperatures  differing 
from  each  other  by  5  or  lO'.  I  therefore  requested 
Mr  Neave,  Bacteriologist  to  the  Hospital  for  Sick 
Children,  to  make  some  investigations  with  regard  to 
this.  Mr  Neave  has  kindly  taken  much  interest  in 
this  research,  and  his  report  is  as  follows  : — 

"  Some  months  ago,  I  undertook  at  your  request  to 
do  what  I  could  to  test  the  cultivation  of  the  pneumo- 
coccus at  the  temperature  of  the  blood,  and  compare 
the  growth  with  that  at  slightly  lower  temperatures.  I 
confess  the  undertaking  was  made  with  a  lighter  heart 
than  the  exigencies  of  the  matter  really  warranted, 
and  that  the  results  arrived  at,  to  say  the  least,  are 
far  from  complete.  It  would  appear  that  each  strain 
of  the  organism  varies  enormously  in  its  idiosyn- 
crasies   of   growth,    and    that    a    change    is    effected 


n.]  BACTERIOLOGICAL  REPORT  63 

after  each  cultivation  on  a  medium  which  has  been 
differently  prepared  in  some  minute  particular.  The 
great  variety  of  statements  as  to  the  nature  and  be- 
haviour of  the  pneumococcus,  I  feel  sure,  is  due  to 
these  inherent  differences.  It  is  open  to  question 
what  exact  value  can  be  put  upon  the  planting  of  a 
number  of  organisms,  and  counting  those  that  grow 
and  make  colonies.  The  late  Dr  Washbourn,  in  his 
Croonian  Lectures,  has  shown  that  in  cultivations  that 
appear  defunct,  if  a  very  large  quantity  is  planted,  one 
or  two  of  surpassing  vitality  may  yet  be  found  to  grow. 
I  have,  however,  not  been  able  to  think  of  any  better 
method  of  testing  the  effect  of  temperature  on  the 
growth  of  this  organism. 

"  In  tlie  first  place,  I  found  that  the  isolation  in 
pure  culture  of  this  organism  was  only  occasionally 
possible,  and  that  pleural-effusion  strains,  which  were 
the  most  easily  obtainable  by  me,  had  hardly  ever 
sufficient  vigour  of  growth  on  artificial  media  to 
enable  a  second  or  subculture  to  be  made  on  a  solid 
medium.  This  was  necessary  for  the  purpose  of 
inoculating  a  plate  with  a  definite  quantity  of  liquid 
medium  containing  a  growth  of  the  organism.  These 
difficulties  I  find  well  described  in  the  Baumgarten 
Jahresbericht,  1900.  However,  by  the  kindness  of 
Drs  Klein  and  Gordon,  an  opportunity  was  given  for 
the  following : — A  colony  isolated  from  sputum  was 
injected  into  mice,  and  the  peritoneal  and  subcu- 
taneous fluids  resulting  proved  to  be  of  exceptionally 


64  PNEUMONIA  [lect. 

vigorous  growth.  In  the  first  plating  the  peritoneal 
fluid  was  diluted  by  sterile  saline  solution,  and  an 
equal  measured  quantity  was  spread  by  a  sterile  glass 
rod  on  two  agar  plates.  One  was  incubated  at  39.4°  C. 
the  other  at  32'  C,  resulting  in  285  colonies  at  the 
higher  temperature  and  15  colonies  at  the  lower.  It 
would  have  been  far  more  satisfactory  to  have  used 
the  same  liquid  at  the  other  temperatures  required  at 
the  same  time,  but  there  were  only  two  incubators  at 
my  disposal.  In  consequence  of  this,  a  fresh  cultiva- 
tion had  to  be  made  every  two  days  and  used  anew 
for  each  subsequent  comparison.  Thus  no  comparison 
between  one  pair  of  groups  and  another  can  be  made. 
In  the  second  comparison  one  plate  was  incubated  at 
37.5''  C.  and  produced  1568  colonies  ;  while  the  second 
at  27.5°  C.  produced  690  colonies.  In  the  third, 
38.5'' C.  produced  153  colonies,  and  32°  C.  produced 
42  colonies. 

'*  The  above,  although  consisting  only  of  one  set  of 
experiments,  conclusively  proves  in  respect  of  that 
particular  strain  of  the  organism,  that  a  temperature 
of  a  few  degrees  less  than  that  of  the  body  prevents 
so  active  a  growth. 

"It  may  be  that  the  comparatively  more  vigorous 
growth  at  the  lower  temperature  in  the  later  experi- 
ments, was  due  to  the  organism  having  been  brought 
up  on  artificial  media,  and  so  had  become  less  virulent. 
It  may  be  noted  that  Dr  Washbourn  points  out 
that  the  non-virulent  varieties  have  a  stronger  growth 


II.]  MORE  RAPID  CONVALESCENCE  65 

at    lower    temperatures    than    those    of   a   virulent 
character." 

These  observations  appear  to  indicate  that  a 
moderate  reduction  of  temperature  does  exercise  a 
marked  inhibitory  influence  on  the  rate  of  growth  of 
the  pneumococcus.  If  they  are  confirmed  by  subse- 
quent and  more  extended  investigations,  they  will 
furnish  a  scientific  justification  of  the  employment  of 
the  icebag  in  the  treatment  of  pneumonia. 

Whether  or  not  this  scientific  basis  can  be  claimed 
for  the  treatment,  any  one  who  will  thoroughly  and 
carefully  employ  it  in  the  manner  already  detailed, 
and  with  the  precautions  above  mentioned,  will  soon 
be  convinced  of  its  practical  usefulness.  Any  estimate 
of  its  yalue  founded  on  the  use  of  one  icebag  only,  in 
cases  seen  only  two  or  three  times  in  the  week,  and 
without  any  careful  percussion  of  the  right  heart  and 
any  attempt  to  relieve  it,  is  worthless. 

One  striking  fact  which  ought  not  to  escape  notice 
is  the  great  improvement  which  an  efficient  ice-treat- 
ment often  produces  in  the  physical  signs  before  the 
crisis.  This  may  be  very  distinct  even  two  or  three 
days  before  the  crisis,  and  already  very  great  indeed 
when  it  occurs.  Another  striking  fact  is  the  more 
rapid  convalescence.  This  is  natural  enough,  for  if 
the  microbic  growth  is  inhibited  there  is  less  poisoning 
of  the  tissues,  less  dead  material  to  be  absorbed  and 
eliminated,  and  less  diminution  of  the  patient's 
strength. 

E 


66  PNEUMONIA  [lect. 

One  point  remains  to  be  noticed.  Some  physicians 
look  upon  pneumonia  as  a  blood-disease  with  local 
lesions,  and  would,  therefore,  consider  the  icebag 
treatment  as  irrelevant  and  useless.  Now  it  is  true 
that  occasionally  pneumococci  have  been  detected  in 
the  blood  of  pneumonic  patients,  but  Dr  Washbourn 
held  that  it  is  only  in  a  few  severe  cases  that  this  can 
be  done.  This  difficulty  in  detection  indicates  that 
the  number  in  the  blood  is  comparatively  small.  In 
whatever  way  the  organisms  may  have  reached  the 
pulmonary  alveoli  in  a  case  of  pneumonia,  whether 
by  inhalation  or  by  the  blood  current,  it  is  certain 
that  their  chief,  probably  in  most  cases  their  only, 
seat  of  multiplication  is  the  lungs.  From  the  lungs 
they  no  doubt  often  pass  into  the  pleura,  sometimes 
into  the  pericardium,  occasionally  into  the  blood 
current,  especially  in  the  worst  cases. 

Dr  Washbourn  has  proved  experimentally  that  it  is 
possible  for  pneumococci  introduced  into  the  air- 
passages  to  pass  through  the  lungs,  and  produce 
pleurisy  and  pericarditis  without  any  implication  of 
the  lung  tissue  itself  Clinically  such  cases  are  met 
with,  but  they  are  much  rarer  than  pneumonia.  Yet 
it  remains  true  that  the  chief  site  of  pneumococcal 
growth  is  in  the  air-cells  of  the  lungs,  and  that  the 
congestion  and  the  production  of  fibrin  are  the  local 
results  of  this  growth  and  of  the  toxins  thereby  pro- 
duced. On  these  points  there  is  some  valuable 
information    in    Dr    Auld's    Selected   Researches    in 


II.]  EXPERIMENTAL  RESULTS  67 

PatJioIogy^  published  in  1901.  He  says  :  "  If  a  pure, 
moderately  virulent  culture  of  the  pneumococcus  be 
inoculated,  either  subcutaneously  or  into  the  internal 
cavities  of  a  susceptible  animal,  it  produces  around 
the  site  of  inoculation  intense  congestion,  exudation 
of  sanguineous  serum,  and  fibrin.  That  is  its 
characteristic  and  invariable  lesion,  and  it  produces 
directly  no  other.  Should  resolution  not  occur  soon, 
we  have,  of  course,  after  a  variable  time,  an  exudation 
of  leucocytes,  the  gradual  collection  of  which  may 
gwQ  rise  ultimately  to  what  has  the  appearance  of  a 
mass  of  pus." 

After  inoculating  beneath  the  skin  of  a  rabbit  rusty 
sputum  from  a  case  of  pneumonia,  and  killing  the 
animal  within  thirty-six  hours,  Dr  Auld  found  that 
its  heart-blood  contained  a  pure  culture  of  the  pneumo- 
coccus. He  grew  these  on  solid  and  liquid  media,  and 
made  injections  into  the  pleural  cavity  of  rabbits, 
causing  always  a  severe  pleurisy,  frequently  severe 
congestion  of  the  lungs,  often  more  or  less  consolida- 
tion, in  two  cases  pneumonic  consolidation  of  an  entire 
lobe,  usually  also  pericarditis.  The  local  lesions, 
lungs,  and  spleen  of  these  rabbits  were  subjected  to 
a  chemical  analysis,  and  from  them  were  obtained  an 
albumose  and  an  organic  acid.  The  latter  gave  the 
reactions  for  lactic  acid  ;  it  was  not  toxic  on  injection 
into  animals.  Dr  Auld  suggests  that  the  production 
of  this  acid  may  have  an  inhibitory  effect  on  the 
further  growth  of  the  pneumococcus. 


68  PNEUMONIA  [lect. 

But  the   albumose  acted   very  differently.     When 
injected  beneath  the  skin  of  the   rabbit's  ear,  local 
inflammation  of  the  ear  was  produced  and  a  rise  of 
temperature  ;  recovery  followed.     Intravenous  injec- 
tion produced  initial  shock,  followed  by  a  marked  rise 
in    temperature,   but    no    other    pathological    effect. 
Injection  into  the  pleural  cavity  produced  no  initial 
depression,  but  marked  dyspnoea  soon  set  in,  followed 
by  rise  of  temperature.    The  animal  was  killed  on  the 
third  day,  and  found  to  have  pleurisy  on  the  right  side, 
with  complete  consolidation  of  the  lower  lobe  of  the 
right  lung.     No  other  lesions  were  found.     Inocula- 
tions were  made  from  the  blood,  and  also  from  the 
serum  in  the  pleural  cavities,  in  solid  and  liquid  media, 
with  a   negative   result.     A   larger   quantity  of  the 
albumose   was    injected    into   the   pleural   cavity   of 
another  rabbit.    Next  day  the  temperature  was  104.6°. 
On  the    following   day  the   animal   was   killed,  and 
severe  right  lateral  and  also  diaphragmatic  pleurisy 
was  found,  with  pericarditis  and  hard  consolidation  of 
the  upper  part  of  the  lower  lobe  of  the  right  lung, 
very  typical  of  ordinary  lobar  hepatization. 

Thus  it  seems  that  the  consolidation  of  lung  in 
pneumonia  is  largely  due  to  the  local  effects  of  an 
albumose  produced  by  the  growth  of  the  pneumo- 
coccus,  and  that  the  pyrexia  and  probably  also  the 
tendency  to  delirium,  are  due  to  its  action  on  the 
brain. 

A    similar    albumose    was    obtained,    in    smaller 


II.]  THE  TOXIC  ALBUMOSE  69 

quantity,  by  growing  the  pneumococcus  in  albuminous 
media  free  from  albumoses,  and  it  was  found  to 
produce  similar  results  on  injection  into  rabbits,  thus 
proving  that  the  pneumococcus  has  the  power  of 
forming  a  highly  toxic  albumose  from  proteid 
material.  Much  larger  doses,  however,  were  required, 
showing  that  the  production  of  toxin  is  much  more 
active  in  the  living  body  than  in  artificial  media. 

Another  interesting  observation  of  Dr  Auld's  may 
also  be  mentioneok  He  found,  by  injection  of  pneu- 
monic toxins  obtained  by  filtration  of  cultures  of  the 
pneumococcus,  that  the  effect  of  such  injections  was 
to  make  the  animals  subjected  to  them  more  susceptible 
to  subsequent  infection  with  the  pneumococcus  than 
normal  animals.  This  susceptibility  appeared  to  last 
for  a  long  period.  The  clinical  importance  of  this  fact 
is  obvious. 


LECTURE  III      ■ 

PNEUMONIA,     EMPYEMA,     PLEURISY,     APPENDICITIS, 
NEPHRITIS 

Pneumonia. 
It  may  be  well  to  combine  the  suggestions  of  the 
preceding  lecture  into  an  outline  plan  of  treatment 
for  pneumonia,  though  it  may  involve  some  repetition. 
Every  case  in  which  a  rigor  occurs  and  the  tempera- 
ture rises  should  be  sent  to  bed  at  once  in  a  well- 
ventilated  room  without  draughts,  the  warmth  of  the 
room  being  maintained  at  60°  F.  If  pneumonia  is 
apparently  developing,  a  trained  nurse  should  be 
obtained  from  the  first.  The  temperature,  pulse-rate, 
and  respiration-rate  should  be  observed,  and  recorded 
on  a  chart,  and  this  should  be  repeated  every  four 
hours.  If  the  patient,  when  first  seen,  is  cold  and  at 
all  collapsed,  it  is  desirable  to  give  him  a  "  hot  pack," 
by  swathing  him  in  a  sheet  wrung  out  of  hot  water  of 
temperature  of  110°  F.  (the  head  being  kept  cool), 
and  covering  him  with  blankets.  Some  hot  brandy 
and  water  may  be  given  to  him  to  drink.  He  should 
be  kept  in  the  pack  for  about  twenty  minutes,  then 


LECT.  III.]  EARLIEST  SIGNS  71 

the  sheet  should  be  removed,  the  patient  dried  quickly, 
and  placed  in  a  warmed  bed. 

When  he  has  thus  been  rendered  warm,  let  the 
practitioner  make  a  careful  examination  of  (i)  the 
tongue,  mouth,  throat,  glands,  (2)  the  left  heart,  (3) 
the  right  heart,  (4)  anterior  pulmonary  regions,  (5) 
posterior  and  lateral  pulmonary  regions,  (6)  liver, 
spleen,  abdomen.  If  pneumonia  is  developing,  it  is 
usually  possible,  by  a  very  careful  percussion,  to 
detect  some  slight  indication  of  the  coming  trouble, 
and  it  is  extremely  important  to  make  sure  of  the 
diagnosis  as  soon  as  possible,  for  before  the  expira- 
tion of  twenty-four  hours  from  the  onset  there  is  a 
chance  of  arresting  the  disease  by  vigorous  treatment. 
There  "will  probably  be  pain  on  one  side  of  the  chest, 
with  somewhat  limited  expansion  of  that  side  in  inspir- 
ation, and  some  slight  local  impairment  of  resonance 
at  base  or  apex.  Over  this  area  there  may  be  a  very 
little  subcrepitant  rdle^  but  the  chief  auscultatory 
indication  will  be  local  feebleness  of  breath  sounds. 
This  comparative  absence  of  breathing  in  the  earliest 
stage  of  pneumonia  is  mentioned  by  Professor  Osier, 
but  is  not  generally  recognised  :  it  is  certainly  a  fact. 

Put  two  hot-water  bottles  to  the  patient's  feet,  and, 
as  soon  as  possible  (every  hour  is  of  importance),  fill 
two  icebags  with  small  fragments  of  ice,  and  apply 
them  as  already  directed  over  the  suspected  part  of 
the  lung,  one  in  front  and  one  behind.  If  the  mouth 
and  fauces  are  foul,  a  sanitas  mouth-wash  should  be 


72  PNEUMONIA  [lfxt. 

employed,  and  the  throat  sprayed  with  perchloride  of 
mercury  lotion  (i  in  2000).  This  should  be  repeated 
every  three  hours  for  the  first  two  days.  It  is  prob- 
ably desirable  in  every  case,  for  the  infection  of  the 
air-passages  doubtless  often  starts  from  the  mouth, 
and  the  spraying  can  be  easily  effected  during  the 
early  days  of  the  attack,  when  there  is  little  dyspnoea. 
The  diet  should  consist  of  milk,  or  milk  and  barley 
water,  given  every  two  hours,  and  water  if  desired. 

The  patient  should  be  seen  again  the  same  evening 
and  again  carefully  examined.  Any  other  area  of 
dullness  that  can  be  detected  should  be  covered  by  a 
third  icebag.  If  pain  in  the  side  has  not  been  already 
relieved  by  the  ice,  a  subcutaneous  injection  of  J  gr. 
to  ^  gr.  of  morphine  should  be  administered,  and  a 
night  draught  of  bromide  and  chloralamide  should  be 
ready  if  the  patient  does  not  sleep.  This  must  on  no 
account  be  overlooked. 

If  the  attempt  at  arrest  is  successful,  on  the  second 
day  the  dullness  will  be  found  not  to  have  increased 
— possibly  it  may  already  have  diminished ;  the  air 
will  enter  the  suspected  area  more  freely,  the  tempera- 
ture will  be  lower,  and  the  pulse-rate  less  frequent. 
It  will  in  this  case  be  necessary  simply  to  persevere 
steadily  with  the  treatment,  but  the  greatest  care 
must  be  employed  to  detect  any  fresh  inflammatory 
foci,  and  to  attack  them  immediately.  Carelessness 
in  percussion  will  lose  the  possible  chance  of  saving 
the  patient  from  a  dangerous  illness. 


III.]  AURKSTED  CASES  73 

In  proof  of  the  assertion  that  if  a  case  of  pneumonia 
comes  under  observation  within  twenty-four  hours 
after  the  initial  rigor,  it  is  sometimes  possible  to  arrest 
it  by  vigorous  treatment,  I  give  the  two  following 
cases : — 

Case  I. — W.  B.,  i8,  carman,  was  seized  on  the 
evening  of  31st  October  1895,  sixteen  hours  before 
his  admission  into  St  Mary's  Hospital,  with  a  rigor 
which  lasted  an  hour.  Next  morning  he  had  fever 
and  pain  in  the  right  side.  On  admission  his  skin 
was  hot  and  dry,  and  there  was  some  labial  herpes. 
Temperature,  103.6";  pulse,  120;  respirations,  40. 
When  I  first  saw  him  on  the  evening  of  ist 
November,  twenty-four  hours  after  the  rigor,  I  found 
dullness  at  the  base  of  the  right  lung  in  front  below 
the  fourth  rib,  extending  into  the  lower  axilla,  with 
some*  tenderness.  The  breath-sounds  were  feeble  over 
the  dull  area.  No  bronchial  breathing,  but  a  little 
crepitation  at  the  end  of  inspiration.  Behind,  at  the 
right  base,  breathing  weak,  and  some  impairment  of 
resonance.     Three  icebags  were  at  once  applied. 

2nd  November. — Temperature,  101.8'';  pulse,  100; 
respirations,  34.  Feels  better.  Dullness  decidedly 
less  extensive. 

'^rd  November.  —  Temperature  100",  rising  to 
101.8",  falling  to  99";  pulse,  100;  respirations,  30. 
Dullness  still  diminishing.     Says  he  is  "  a  lot  better." 

A^th  November.  —  Temperature,  98° ;  pulse,  72  ; 
respirations,  26.  Now  only  a  small  dull  area  in  lower 
axilla.     Ice  removed  (after  sixty  hours). 

^th  November. — Temperature  rose  to  99.8",  but  fell 
to  98°. 

6th  November. — Temperature  rose  to  100.2",  but 
fell  to  98". 

"jth  November. — Temperature,  normal ;    pulse,   64 ; 


74  PNEUMONIA  [lect. 

respirations,  20.     Very  slight  impairment  of  reson- 
ance could  now  be  detected. 

Case  1 1. — E.  N.,  14,  admitted  22nd  May  1896, 
twenty-four  hours  after  immersion  in  a  canal  and 
twelve  hours  after  a  rigor.  He  had  a  headache  and 
dyspnoea.  On  admission,  dullness  was  found  in  the 
right  axillary  region,  and  an  icebag  at  once  applied. 
Temperature,  103°;  pulse,  120;  respirations,  40. 

2ird  May  (10  A.M.). — Both  cheeks  very  flushed. 
Obvious  dyspnoea.  Temperature,  103°;  pulse,  120; 
respirations,  40.  Dull  in  the  right  lower  axilla,  not 
behind  scapular  line  nor  to  inner  side  of  nipple.  Just 
below  angle  of  right  scapula  there  was  distinct  fine 
crepitation,  with  inspiration  only  ;  this  was  so  typical 
that  I  made  all  my  clinical  clerks  listen  to  it.  Breath 
sounds  diminished  over  the  dull  area  ;  no  bronchial 
breathing.  Dullness  and  diminished  breathing  in 
right  suprascapular  fossa  also.  Some  pain  on  left 
side  of  abdomen  on  taking  a  deep  breath,  but  no  rub 
could  be  heard  and  there  was  no  dullness.  Heart 
normal.  Three  more  icebags  were  ordered,  making 
four  in  all ;  two  to  the  right  base,  a  third  over  the 
right  apex  behind,  and  the  fourth  over  the  left  axilla. 
After  one  hour  the  temperature  fell  to  100",  and  the 
ice  was  removed.  It  then  rose  to  102°,  but  at  once 
fell  again. 

24//^  May — (forty-eight  hours  after  the  rigor). 
Temperature,  normal  ;  pulse,  74 ;  respirations,  34. 
He  had  slept  well,  was  now  not  flushed,  and  the  right 
axilla  was  less  dull.  The  temperature  remained  sub- 
normal for  thirty-six  hours.  There  was  a  short  rise 
to  100"  on  the  25th,  and  to  99.5''  on  the  26th.  After 
this  it  was  normal,  and  the  boy  was  quite  well,  and 
the  right  axillary  region  was  of  normal  resonance. 

It  will  be  observed  that  in  each  of  these  cases  there 


III.]      RAPID  GROWTH  OF  PNEUMOCOCCUS        75 

was  no  crisis,  but  an  immediate  and  rapid  subsidence 
of  temperature,  physical  signs,  and  symptoms.  In 
such  cases  as  these  it  is  reasonable  to  claim  that  the 
disease  has  been  arrested.  But  it  is  not  always 
possible  to  arrest  a  pneumonia  even  when  it  is  treated 
very  early,  and  after  twenty-four  hours  there  is  little 
hope  of  success.  This  is  not  surprising  when  we 
remember  how  rapidly  micro-organisms  increase  in 
number  under  favourable  circumstances.  Washbourn 
and  Eyre  found,  on  cultivating  the  pneumococcus  in 
nutrient  broth,  making  plate-cultivations  from  the 
broth-culture  and  counting  the  living  cocci  present  at 
different  periods^  that  140  colonies  increased  in  three 
hours  to  6149,  and  in  six  hours  more  to  13,680; 
twelv^  hours  later  they  were  "  innumerable." 

As  the  normal  temperature  of  the  human  body  is 
only  i^  F.  below  the  optimum  temperature  for  the 
growth  of  the  pneumococcus,  it  is  clear  that  if  an 
attempt  to  arrest  the  development  of  a  pneumonia  is 
to  have  any  chance  of  success,  it  must  be  made  very 
early  and  very  vigorously. 

But  it  is  always  possible  to  influence  the  course  of 
a  pneumonia,  to  diminish  its  intensity,  and  often  to 
shorten  its  duration.  This  of  course  is  difficult  to 
prove,  because  of  the  uncertainty  of  the  time  of 
occurrence  of  the  crisis  in  the  disease  when  untreated. 
But  there  is  nothing  really  improbable  in  the  assertion 
that  there  is  reason  to  believe  that  the  ice-treatment 
sometimes  brings  about  an  earlier  crisis.     For  how- 


76  PNEUMONIA  [lect. 

ever  the  crisis  may  be  caused,  whether  by  the  manu- 
facture of  an  antitoxin  or  by  a  faijure  of  further 
growth  of  the  pneumococcus,  it  seems  clear  that  any 
treatment  which  can  to  any  extent  inhibit  the  growth 
of  the  microbe  and  thus  check  the  amount  of  toxin 
which  it  produces,  will  to  that  extent  facilitate  the 
earlier  termination  of  the  struggle  between  the 
attacking  and  the  defending  forces ;  in  other  words,  it 
will  hasten  the  crisis. 

If  the  attempt  to  arrest  the  disease  is  unsuccessful, 
on  the  second  day  the  area  of  dullness  will  be  larger, 
and  over  it  may  be  heard  inspiratory  crepitation,  or 
sharp  rales  of  double  rhythm  in  children,  or  some 
prolonged  expiration,  or  distinctly  bronchial  breath- 
ing. A  third  or  a  fourth  icebag  should  now  be 
applied,  the  sites  for  their  application  being  outlined 
in  blue. 

It  is  desirable  at  this  period  to  administer  2  or 
3  grains  of  calomel,  followed  after  three  hours  by 
a  seidlitz  powder.  When  a  sufficient  evacuation  has 
been  obtained  the  purgative  should  not  be  repeated, 
for  in  the  later  days  of  a  pneumonia  there  is  a 
tendency  to  diarrhoea. 

On  the  second  evening  the  hypnotic  must  be  given 
again  if  necessary,  and  morphine  if  pain  is  present, 
for  the  patient  must  have  sleep.  It  may,  perhaps,  be 
desirable  to  remove  one  or  two  of  the  icebags  during 
the  night,  leaving  two  only  in  position.  It  might  be 
thought   that   the    necessary   disturbance   would    be 


III.]  VALUE  OF  LEFXHES  77 

fatal  to  sleep,  but  the  relief  of  pain  and  dyspnoea  is 
so  great  that  the  patient  easily  falls  asleep  again, 
provided  that  his  right  heart  is  not  over-full.  In  the 
case  of  young  children  the  temperature  should  now  be 
taken  every  two  hours  (hourly  for  babies),  and  it  can 
be  done  without  disturbing  them.  If  any  icebags 
have  been  removed  at  night,  they  should  be  replaced 
early  next  morning. 

On  the  third  morning  the  physical  signs  in  the 
lungs  must  again  be  most  carefully  determined,  and 
directions  given  for  the  alterations  of  position  of  the 
icebags  necessitated  by  the  changes  found.  But  now 
special  attention  must  be  given  to  the  right  heart. 
If  the  dullness  of  the  right  auricle  is  found  to  extend 
two  ''fingerbreadths  in  the  fourth  right  space,  and 
there  is  distinct  dyspnoea  and  some  slight  lividity  of 
lips,  or  cheeks,  or  finger-tips,  leeches  should  be 
applied  over  the  lower  ribs  on  the  right  side  below 
the  nipple-level.  One  should  be  used  for  a  baby 
under  six  months,  two  for  a  child  under  two  years, 
four  for  a  child  of  ten  years,  six  for  an  adult,  eight  for 
a  robust  man.  If  not  used  at  once,  the  leeches  should 
be  held  in  readiness,  for  they  may  possibly  be 
required  in  the  evening  if  the  patient  is  to  sleep. 
Some  "  malted  milk,"  and  one  or  two  cylinders  of 
compressed  oxygen  should  be  procured. 

On  the  third  evening  it  will  in  most  cases, 
unless  the  ice  has  already  caused  a  marked  improve- 
ment in    the    physical    signs,  be   advisable  to   apply 


78  PNEUMONIA  [lect. 

leeches — if  they  have  not  been  already  used — an  hour 
or  two  before  the  time  for  sleep.  The  relief  thus 
given  to  the  right  heart  will  often  induce  sleep  with- 
out any  hypnotic,  but  one  must  be  given  if  needful. 
Even  morphine  may  be  used  safely  under  these 
circumstances. 

On  the  fourth  morning,  if  the  leeches  have  been 
applied,  the  patient  will  feel  more  comfortable,  though 
the  physical  signs  may  have  increased  in  extent. 
The  same  minute  care  in  determining  the  physical 
signs  in  both  lungs  must  be  practised.  Watch  care- 
fully for  fresh  areas  of  dullness,  especially  if  there  has 
been  any  fresh  rise  of  temperature,  and  attack  them 
at  once. 

The  right  auricle  having  now  been  relieved,  it  will 
be  desirable  to  give  considerable  quantities  of  water, 
both  to  satisfy  thirst,  and  to  promote  diuresis  and  the 
elimination  of  toxin.  During  the  twenty-four  hours 
following  the  use  of  the  leeches,  3  or  4  pints  of  water 
may  be  given,  in  quantities  of  8  to  10  oz.  every  three 
hours  ;  for  a  child,  4  to  6  oz. 

If  the  patient  has  not  come  under  treatment  until 
the  fourth  day  of  a  severe  attack,  he  will  probably  be 
in  considerable  distress.  Dyspnoea  and  discomfort 
will  be  marked,  cyanosis  distinct,  and  the  dullness  of 
the  right  auricle  may  measure  from  two  to  two  and  a 
half  fingerbreadths  in  the  fourth  space,  one  or  one  and 
a  half  in  the  third,  and  half  a  fingerbreadth  or  more 
in  the  second.     This  should  be  ascertained  at  once, 


III.]  DETAILS  OF  TREATMENT  79 

before  any  attempt  is  made  to  discover  the  amount  of 
disease  in  the  lungs.  The  call  for  bleeding  is  urgent 
and  imperative.  A  larger  number  of  leeches  must 
now  be  used  than  would  have  sufficed  on  the  previous 
day.  Two  must  be  employed  for  a  baby,  three  for  a 
young  child,  four  to  six  for  an  older  child,  eight  to 
twelve  for  an  adult.  A  venesection  is  often  prefer- 
able :  4  oz.  for  a  young  adult,  8  oz.  for  a  strong  man. 

An  hour  after  the  bleeding  both  lungs  should  be 
carefully  examined  and  the  outlines  of  the  dull  areas 
marked  on  the  chest.  Two  icebags  must  be  applied 
at  once  to  the  worst  inflammatory  foci,  an  hour  or 
two  later  a  third,  and  before  long  a  fourth.  We  are 
now  in  the  thick  of  the  fight,  and  it  is  necessary  to 
call  up  the  reserves  and  have  all  our  forces  in  readi- 
ness for  the  struggle  of  the  next  three  or  four  days. 
The  subcutaneous  injection  of  strychnine  should  be 
begun  and  maintained  systematically  in  increasing 
amount  or  frequency.  Now  is  the  time  also  to  begin 
the  administration  of  oxygen  ;  this,  too,  should  be 
regularly  continued  throughout.  Milk  and  also  water 
may  be  given  in  considerable  quantities  after  the 
venesection.  At  night  sleep  will  probably  come 
naturally,  the  right  heart  having  been  relieved,  and 
the  pulmonary  congestion  diminished  by  the  ice,  but 
if  not  a  hypnotic  must  be  given,  and  even  morphine 
if  necessary  ;  the  patient  must  have  sleep. 

On  the  fifth  day,  if  the  patient  has  been  vigorously 
treated  with  leeches  and  ice,  there  is  often  a  marked 


80  PNEUMONIA  [lect. 

improvement  in  the  physical  signs,  and  much  less 
tendency  to  extension.  But,  if  this  be  not  the  case, 
it  will  now  be  desirable  to  limit  the  amount  of 
fluid  given  to  the  patient,  so  as  to  lessen  the 
strain  on  the  right  heart.  The  diet  for  the  next 
two  or  three  days  may  be  simply  malted-milk 
powder  dissolved  in  milk,  a  tablespoonful  in  2 
oz.  hourly  for  an  adult,  two  teaspoonfuls  in  i  oz.  for 
a  child,  while  awake.  The  icebags  must  be  con- 
tinuously applied,  and  their  position  altered  as  may 
be  necessary,  special  care  being  taken  to  discover  and 
attack  fresh  or  spreading  areas  of  inflammation.  If 
leeches  have  been  used  on  the  third  day,  it  is  desirable 
to  examine  the  right  heart  again  very  carefully  on 
the  evening  of  the  fifth  day.  The  relief  will  almost 
always  last  for  forty-eight  hours,  but  by  the  fifth 
evening  some  more  leeches  may  be  required.  In 
determining  this  point,  especially  when  the  left  lung 
is  mainly  involved,  it  is  very  necessary  to  guard 
against  being  misled  by  overdistension  of  the  right 
lung  into  an  underestimate  of  the  size  of  the  right 
auricle.  In  case  of  doubt,  let  the  decision  be  for  the 
leeches.  The  amount  of  sleep  which  the  patient  has 
hitherto  obtained  is  also  of  importance  in  deciding 
this  question.  If  he  has  slept  well,  and  the  right 
auricle  does  not  measure  more  than  two  finger- 
breadths,  the  leeches  may  be  postponed.  But  if 
sleep  has  been  defective,  it  will  be  wiser  to  apply 
them,  and  afterwards  to  give  a  hypnotic.     For  sleep 


III.]  THE  LATER  DAYS  81 

is  of  great  importance  for  the  maintaining  of  vigour 
for  the  days  which  may  remain. 

If  the  patient  has  reached  the  fifth  or  sixth  day  of 
his  illness,  and  neither  blood-letting  nor  ice  has  been 
employed,  the  symptoms  are  often  very  severe,  the 
distress  great,  and  the  outlook  gloomy.  Probably  he 
has  been  sleepless  for  several  nights,  and  his  strength 
is  rapidly  diminishing.  The  call  for  active  treatment 
is  urgent.  The  prognosis  depends  on  three  factors  : 
the  age  and  previous  health  of  the  patient,  the 
intensity  of  the  infection,  and  the  action  of  the  medical 
attendant.  At  such  a  time  the  responsibility  of  the 
latter  is  great ,  indeed.  Life  is  trembling  in  the 
balance.  His  action  or  his  inaction  may  decide 
whetlier  or  not  the  patient  shall  be  deprived  of  many 
years  of  life,  and  his  wife  and  children  suffer  an 
irreparable  loss. 

The  first  necessity  is  a  venesection.  Eight  ounces 
of  blood  should  be  taken  at  once,  twice  as  much  or 
more  if  the  lung  be  full  of  rales.  If  permission  for 
venesection  cannot  be  obtained,  place  a  dozen  leeches 
over  the  liver  and  encourage  the  bleeding.  Hypo- 
dermic injections  of  strychnine  in  3-minim  doses  every 
four  hours  should  follow  immediately,  and  the  syste- 
matic inhalation  of  oxygen  for  ten  minutes  or  more 
every  hour.  Two  icebags  should  be  at  once  applied, 
soon  followed  by  a  third,  and  before  long  by  a  fourth. 

It  is  very  probable  that  after  this  treatment  the 
patient  will  fall  asleep.      If  so,  he  should  be  undis- 

F 


82  PNEUMONIA  [lect. 

turbed  for  four  or  six  hours.  But  after  this  time 
nourishment  must  be  given  and  the  icebags  refilled 
every  two  hours.  Malted-milk  in  milk  with  a  little 
brandy  should  be  given  every  hour  when  he  awakes, 
and  all  medicine  by  the  mouth  avoided.  After  sleep 
has  been  obtained  a  small  enema  may  be  given  if 
necessary.  If  diarrhoea  is  present,  the  rectum  should 
be  washed  out  with  warm  saline  solution,  and  2  oz. 
of  starch  decoction  with  a  few  drops  of  tincture  of 
opium  inserted. 

Some  improvement — often  much — will  certainly 
follow  this  treatment  unless  the  patient  be  already 
very  far  on  the  downward  road,  or  his  heart  be 
previously  dilated,  his  lungs  emphysematous,  his  liver 
cirrhosed,  or  his  kidneys  granular.  Many  cases  are 
no  doubt  hopeless  from  the  first ;  but  not  very  rarely 
an  apparently  hopeless  case  recovers ;  and,  at  all 
events,  whatever  can  be  done  to  give  a  chance  of 
recovery  ought  to  be  done.  Here  let  me  put  in  a 
plea  for  earlier  consultations.  Too  often  a  "  second 
opinion  "  is  sought  for  only  when  death  is  imminent. 
The  surgeon  is  right  in  asking  that  he  may  be 
allowed  to  see  a  case  of  perforated  gastric  ulcer  as 
soon  as  the  diagnosis  is  made;  if  twenty-four  hours 
are  allowed  to  elapse,  the  patient's  chance  of  recovery 
is  small  indeed.  It  is  estimated  by  Mr  Mayo 
Robson  that  if  operated  on  within  twelve  hours  after 
the  perforation  the  mortality  is  only  16.6  per  cent. ;  if 
within    twenty-four   hours,    it    is   63.0   per   cent. ;    if 


III.]  THE  CRISIS  83 

within  thirty-six  hours,  it  is  87.5  per  cent. ;  and  if 
delayed  for  forty-eight  hours,  the  operation  will  only 
rarely  succeed.  So  may  the  physician  plead  that  in 
pneumonia  the  final  issue  largely  depends  on  the 
treatment,  or  want  of  treatment,  during  the  first  few 
days.  In  the  case  of  an  infant,  or  of  an  adult  older 
than  30  years,  the  danger  to  life  is  great,  and  judicious 
treatment  is  required  from  the  very  first.  This  is  not 
so  obvious  to  the  patient  as  when  an  operation  is 
required,  but  it  ought  to  be  equally  obvious  to  the 
practitioner.  To  delay  the  consultation  in  such  a 
case  to  the  fourth  or  fifth  day  is  to  imperil  the 
patient's  life. 

Pneumonia  in  adults  usually  ends  by  a  very  rapid 
fall  of  temperature,  with  slowing  of  pulse.  This 
"  crisis "  often  occurs  in  children  also,  even  in  cases 
which  would  be  designated  as  "  bronchopneumonia," 
but  in  children  the  subsidence  is  apt  to  be  more 
gradual,  and  to  occupy  several  days.  Pneumonia  in 
children  sometimes  lasts  for  three  or  even  four  weeks. 
It  is  necessary  to  keep  a  careful  watch  for  the  first 
indications  of  this  quick  diminution  of  temperature, 
especially  in  children.  The  icebags  should  be  gradu- 
ally removed  as  the  temperature  falls,  and  the  last 
should  be  taken  off  when  the  thermometer  marks 
100"  F.  There  is  a  natural  tendency  to  collapse  at 
the  time  of  the  crisis  which  must  be  kept  in  mind. 
Icebags  over  the  chest  at  this  stage  would  probably 
be  injurious,  though  in  pericarditis,  as  I  have  already 


84  PNEUMONIA  [lect. 

mentioned,  they  may  sometimes  be  used  with 
advantage,  even  when  the  temperature  is  subnormal. 
If,  in  spite  of  care,  or  for  want  of  it,  the  reduction  of 
temperature  is  so  great  as  to  cause  some  collapse, 
it  is  desirable  to  apply  warmth  over  the  heart  and 
abdomen,  also  to  the  feet,  and  to  give  the  patient 
some  hot  water  with  brandy,  and  a  draught  containing 
ether  and  ammonia.  By  these  means  it  is  usually 
easy  to  remove  any  tendency  to  collapse. 

But  the  crisis  is  often  preceded  by  a  remission  of 
temperature  which  lasts  only  a  few  hours.  Hence, 
when  the  ice  has  been  removed,  the  temperature 
should  still  be  taken  every  hour.  If  it  rises  to 
loi"  F.  a  single  icebag  should  be  again  applied,  if  to 
103'^  F.  at  least  two.  Much  careful  observation  on  the 
part  of  the  nurse  is  required  at  this  period.  If  the 
temperature  shows  a  persistent  tendency  to  keep 
above  normal  after  the  crisis  has  occurred,  the 
existence  of  empyema  should  be  suspected,  and  an 
exploring  needle  should  be  passed  into  the  dullest 
area.     Occasionally  it  may  be  due  to  tuberculosis. 

Empyeina. 
The  frequent  occurrence  of  empyema  as  a  chronic 
condition  following  an  attack  of  pneumonia  is  well 
recognised,  but  I  wish  to  call  attention  to  what  may 
be  termed  acute  empyema,  in  which  the  pneumococcal 
invasion  mainly  or  exclusively  involves  the  pleura,  the 
lung  being  little   affected,  perhaps  not  at  all.     This 


III.]  EMPYEMA  85 

seems  to  be  more  common  in  children,  but  it  may  occur 
in  adults.  In  a  young  child  in  the  Hospital  for  Sick 
Children,  who  had  a  temperature  of  106''  F.  and 
dullness  over  one  base,  and  who  was  thought  to  be 
suffering  from  pneumonia,  the  necropsy  revealed  a 
considerable  amount  of  turbid  fluid  in  the  pleural 
cavity,  but  no  consolidation  of  lung.  In  a  girl 
recently  under  my  care  at  St  Mary's  Hospital,  3  oz. 
of  pus  were  obtained  from  the  left  pleura  as  early  as 
the  eighth  day  of  an  attack  which  was  at  first 
thought  to  be  merely  pneumonia,  but  in  which  the 
extensive  dullness,  feeble  breath-sounds,  and  cardiac 
displacement  soon  suggested  pleural  effusion.  I  think 
that  in  this  case  some  pneumonia  was  present  also,  for 
cyaifbsis  was  well  marked,  and  the  dullness  of  the  right 
auricle  in  the  fourth  right  space  measured  two  and  a 
half  fingerbreadths  on  the  third  day  of  the  illness. 

When  the  amount  of  pus  in  the  pleura  is  small  and 
localised  by  adhesions,  it  is  often  extremely  difficult 
of  diagnosis.  Probably  few  physicians  have  escaped 
the  mortifying  experience  of  the  post-mortem  dis- 
covery of  an  empyema  which  had  been  overlooked,  or 
diagnosed  as  some  other  condition.  The  difficulty  of 
diagnosis  is  similar  to,  though  not  quite  so  great  as, 
the  difficulty  in  suppurative  pericarditis,  and  the  two 
conditions  are  sometimes  associated.  There  may 
be  a  small  amount  of  pus  in  both  pleurae  as  well  as 
in  the  pericardium ;  it  is  rare  to  find  any  in  the 
peritoneum. 


86  EMPYEMA  [lect. 

A  localised  empyema  may  be  diagnosed  as  a 
pneumonia,  as  a  serous  pleural  effusion,  as  a  bron- 
chiectasis, as  tuberculous  consolidation  of  lung,  as 
collapse  of  lung,  or  as  a  subphrenic  abscess,  and  the 
diagnosis  may  be  impossible  without  the  exploring 
needle.  The  signs  of  distinction  between  a  consoli- 
dated lung  and  a  pleural  effusion  may  be  neatly  stated 
and  tabulated  in  text-books,  but  there  is  not  one 
of  them  which  may  not  prove  fallacious  in  practice. 
The  temperature  may  be  high  in  an  acute  empyema  ; 
it  may  be  low  in  pneumonia.  The  breath-sounds  are 
sometimes  audible  in  children  over  a  pleural  effusion, 
and  they  may  be  quite  inaudible  in  an  influenzal 
bronchopneumonia,  or  in  the  later  stages  of  a  lobar 
pneumonia.  Even  displacement  of  the  heart  is  not 
certain  proof  of  a  pleural  effusion,  at  all  events  in 
children  ;  it  may  sometimes  be  caused  in  them  by  a 
solid  lung.  This  is  especially  true  of  a  form  of 
tuberculous  disease  of  the  lung  in  which  the  lower 
and  middle  lobes  on  the  right  side  are  attacked  by 
tubercle  spreading  from  the  bronchial  glands.  This 
occurrence  is  not  very  rare  in  children,  and  my 
colleague,  Dr  Batten,  has  shown  from  post-mortem 
observations  that  it  is  much  more  frequent  on  the 
right  side  than  on  the  left.  Clinically  this  condition 
may  cause  all  the  physical  signs  of  a  pleural  effusion, 
including  some  displacement  of  the  heart,  as  I  have 
seen  in  a  case  in  which  an  incision  revealed  a  healthy 
pleura,  with  solid  lung  beneath.     In   some   cases  a 


III.]  DIFFICULTIES  OF  DIAGNOSIS  87 

small  localised  empyema  between  the  lobes  of  the 
lung  may  coexist,  as  in  a  girl  under  my  care  at  Great 
Ormond  Street.  In  this  case  Mr  Collier  succeeded 
in  draining  the  small,  deep-seated  cavity,  and  the 
patient  gradually  recovered. 

The  danger  of  overlooking  an  empyema  which  is 
small,  or  even  of  moderate  size,  is  so  great  that  it 
should  always  be  kept  in  mind,  and  an  exploring 
needle  should  be  passed  if  there  is  any  room  for 
doubt.  If  the  first  puncture  does  not  yield  pus,  an 
anaesthetic  should  be  given,  and  punctures  made  in 
other  sites  of  dullness.  If  pus  is  found,  an  incision 
should  at  once  be  made,  a  piece  of  rib  removed,  and 
a  drainage  tube  inserted. 

Pleurisy. 

Acute  pleurisy  in  its  earliest  stages  may  be  very 
successfully  treated  with  ice  to  the  chest.  One  icebag 
is  often  sufficient ;  it  should  be  applied  over  the  spot 
where  friction  is  audible.  It  quickly  relieves  pain,  and 
often  renders  morphine  unnecessary,  though  it  might 
be  wise  to  give  a  small  amount  of  this  drug  hypo- 
dermically  if  the  pain  were  very  severe.  Two  icebags 
may  be  used  if  necessary.  The  friction  often  rapidly 
disappears  after  the  ice  has  been  applied  for  some 
hours,  and  the  tendency  to  effusion  is  very  decidedly 
checked.  As  an  illustration  of  this  beneficial  effect, 
I  may  mention  a  recent  case  of  dermoid  cyst  of  the 
right  thorax  under  my  care  at  St  Mary's  Hospital : 


88  PLEURISY  [lect. 

A  large  cyst  displaced  the  heart  into  the  left  axilla 
and  compressed  the  right  lung.  By  four  distinct 
operations,  at  considerable  intervals,  Mr  Silcock 
succeeded  in  removing  the  whole  of  the  wall  of  the 
cyst,  dissecting  it  off  the  diaphragm,  the  right  pleura, 
and  the  pericardium.  On  the  day  following  the  last 
of  these  operations  the  patient  complained  of  pain  in 
the  left  side,  and  the  temperature  rose.  Over  the 
cardiac  region  and  to  the  left  of  it  a  fine  crepitant 
friction  could  be  heard,  with  the  respiration  only.  An 
icebag  was  applied.  Next  day  there  was  a  definite 
pleural  rub  in  the  left  axilla,  and  pain  continued, 
though  less  intense. 

On  the  day  following  the  pain  was  much  relieved 
and  the  rub  less  marked,  but  there  was  much  inspira- 
tory dyspnoea,  both  sternomastoids  acting  strongly 
with  each  inspiration.  It  was  impossible  to  determine 
accurately  the  extent  of  the  dullness  of  the  right 
auricle,  owing  to  the  previous  condition  and  to  the 
operation,  but  it  was  clear  that  it  was  greatly  over- 
strained through  the  occurrence  of  pleurisy  and 
probably  acute  pulmonary  congestion  in  the  single 
lung  that  was  able  to  perform  the  respiratory  process. 
We  were  very  reluctant  to  submit  the  patient  to  any 
further  loss  of  blood,  and  fortunately  we  succeeded 
by  a  subcutaneous  injection  of  morphine  and  atropine 
in  escaping  this  necessity.  Next  day  the  danger  was 
past,  and  the  patient  steadily  recovered. 

I  think  it  is  practically  certain  that  but  for  the 
icebag  this  patient  would  have  died. 

In  the  treatment  of  a  large  serous  effusion  ice 
externally  is  very  useful,  but  it  should  be  preceded 
by  paracentesis.  As  soon  as  it  is  evident  that  there 
is  a  considerable  amount  of  fluid  in  the  pleura,  it  is 


III.]  TREATMENT  BY  ICE  89 

best  to  aspirate  at  once,  under  low  pressure,  and  draw 
off  as  much  fluid  as  comes  easily.  Then  fix  this  side 
of  the  chest  with  broad  bands  of  strapping  firmly 
applied,  and  over  the  strapping  apply  two,  or  three, 
icebags.  This  treatment  rapidly  relieves  the  discom- 
fort and  dyspnoea,  and  any  pain  that  may  be  present. 
If  the  ice  is  maintained  in  position  for  about  two  days 
there  is  usually  little  tendency  to  reaccumulation  of 
fluid.  But  if  a  relapse  does  occur,  it  may  be  treated 
in  the  same  way,  and  the  ice  applied  for  a  longer 
period.  The  serous  fluid  obtained  by  paracentesis 
in  such  cases  is  usually  sterile  ;  it  is  probably  often 
jdue  to  tuberculosis  affecting  the  pleura.  It  is  fre- 
quently possible  to  obtain  physical  evidence  of  this 
by  a  careful  examination  of  the  opposite  lung,  for 
there  is  in  many  such  cases  more  or  less  dullness  and 
feebleness  of  breath  sounds  at  the  inner  end  of  the 
first  space  and  over  the  posterior  part  of  the  upper 
apex,  also  below  the  apex  of  the  lower  lobe.  This  is 
the  more  striking  because  the  rest  of  this  lung  is  often 
hyper-resonant. 

In  an  acute  local  pulmonary  tuberculosis  icebags 
applied  over  the  dull  apices  often  give  much  comfort, 
and  appear  sometimes  to  be  of  distinct  service  in 
checking  the  rapid  progress  of  the  disease.  This  is 
especially  the  case  when  the  temperature  is  high. 

In  acute  laryngitis  an  icebag  placed  over  the  larynx 
gives  rapid  relief  to  the  symptoms,  and  in  a  catarrhal 
laryngitis  is  curative, 


90  APPENDICITIS  [lect. 

In  local  peritonitis  over  gastric  ulcer,  with  threaten- 
ing perforation,  ice  over  the  epigastrium  brings  much 
comfort  to  the  patient,  and  greatly  aids  the  subsidence 
of  symptoms. 

Appendicitis. 
In  the  treatment  of  inflammations  of  the  appendix 
vermiformis  the  persistent  application  of  an  icebag  is 
far  more  effective  than  fomentations  or  poultices;  it 
rapidly  relieves  pain,  and  obviously  diminishes  the 
local  inflammation.  Clinically,  cases  of  appendix- 
inflammation  may  be  divided  into  three  groups.  The 
first  and  most  important  group  consists  of  cases  of 
perforation  of  the  appendix,  with  escape  of  con- 
cretions or  of  pus  into  the  peritoneal  cavity,  or  of  a 
gangrenous  condition  of  the  appendix  itself.  Such 
cases  are  usually  of  sudden  onset,  and  the  symptoms 
often  severe.  Pain,  vomiting,  tenderness,  rigidity 
of  abdominal  muscles,  flexion  of  the  thigh,  limita- 
tion of  descent  of  diaphragm  during  inspiration, 
tympanites  but  often  no  local  tumour,  with  evidence 
of  septic  absorption,  are  the  chief  indications.  Such 
cases  demand  immediate  operative  interference ; 
every  hour  is  of  importance.  They  are  similar 
to  cases  of  perforated  gastric  ulcer,  or  to  a  strangu- 
lated hernia.  No  question  of  palliative  treatment 
must  be  entertained  for  a  moment.  The  absorp- 
tion of  septic  material  from  the  peritoneum  is  often 
very  rapid,  and  a  delay  of  a  few   hours  may   make 


III.]  PERFORATION  AND  GANGRENE  91 

all  the  difference  between  life  and  death.  No  such 
case  ought  to  be  allowed  to  die  without  operation  ; 
not  seldom,  apparently  desperate  cases  have  been 
rescued.  The  operation  ought  never  to  be  delayed 
because  of  the  collapsed  condition  of  the  patient ; 
it  is  the  most  effectual  means  of  removing  the 
collapse — often  the  only  chance. 

The  cases  of  the  second  group  jire  much  more 
common.  They  are  often  due  to  a  subacute  inflamma- 
tion of  the  appendix,  which  may  be  thickened. 
The  symptoms  are  comparatively  slight,  but  there 
is  usually  some  definite  local  tenderness,  and  often 
a  tender  local  swelling  can  be  detected,  with  dull- 
ness on  percussion  over  it.  This  swelling  may 
sometimes  be  due  to  a  local  muscular  contraction  in 
the  abdominal  wall,  as  suggested  by  Dr  Mackenzie, 
but  it  certainly  appears  in  some  cases  to  be  the 
thickened  appendix  itself  which  is  felt. 

These  cases  will  usually  recover  in  time  under  any 
or  under  no  treatment,  but  they  are  prone  to  relapse. 
Fomentations  or  poultices  give  some  relief  to  dis- 
comfort, but  they  do  not  cause  rapid  subsidence  of 
the  swelling  and  of  the  symptoms.  This,  however, 
is  often  promptly  effected  by  an  icebag,  the  results 
produced  by  which  are  sometimes  very  striking. 

Intermediate  between  these  two  groups  of  cases, 
clinically  speaking,  is  a  third  group,  in  which  the 
symptoms  are  very  definite,  but  not  so  acute  as  to 
make  it  clear  that  immediate  operation  is  required. 


92  APPENDICITIS  [lect. 

There  is  usually  a  distinct  local  fullness  and  tender- 
ness. The  practitioner  is  in  doubt  whether  pus  has 
already  formed,  and  whether  an  incision  ought  to  be 
made  at  once  or  delayed.  In  this  difficulty,  which  is 
by  no  means  rare,  and  in  which  a  correct  decision  is 
of  the  greatest  importance,  I  have  found  that  the 
application  of  an  icebag  for  three  or  four  hours  will 
often  give  the  necessary  guidance.  If  after  four  hours 
the  ice  has  not  given  distinct  relief,  an  operation 
should  be  performed  without  further  delay.  But  if 
there  be  definite,  even  though  slight,  alleviation  of 
symptoms,  the  operation  may  be  postponed  for  a 
short  time  and  further  trial  made  of  the  icebag.  In 
many  cases  after  twenty- four  hours  the  relief  is  so 
definite  that  no  further  question  of  immediate  opera- 
tion need  be  entertained.  If  the  improvement  con- 
tinue, the  icebag  should  be  kept  in  place  persistently 
for  two  or  three  weeks,  with  absolute  rest  in  bed. 
Such  cases  must  be  very  carefully  watched,  for  a 
small  local  abscess  may  remain  and  may  require 
incision  at  a  later  period.  But  the  condition  will 
then  be  much  more  favourable  for  operation  than  at 
first,  the  pus  will  be  well  localised,  and  the  surround- 
ing inflammation  quieted  down.  On  the  other 
hand,  if  the  early  relief  is  not  maintained,  although 
the  icebag  has  been  applied  persistently,  it  will 
usually  be  wise  not  to  delay  the  operation  any  longer. 
Thus  the  icebag  becomes  a  useful  test  by  which  we 
may  decide  the  often  difficult  and  anxious  question 


III.]  VALUE  OF  THE  ICEBAG  93 

as  to  whether  or  not  an  operation  ought  to  be  per- 
formed. 

If  recovery  has  occurred  without  operation,  it  must 
be  decided  whether  or  not  the  appendix  should  be 
removed.  If  this  is  the  first  occasion  on  which  it  has 
offended,  and  the  symptoms  have  been  slight,  it  may 
surely  be  allowed  another  chance,  though  this  is  not 
the  opinion  of  the  most  "  advanced  "^surgeons.  But 
if  the  symptoms  have  been  severe,  or  if  it  be  a  second 
offence,  probably  removal  after  a  short  period  of  con- 
valescence is  desirable. 

Acute  Nephritis. 

The  last  form  of  acute  visceral  inflammation  of 
which  I  desire  to  speak  is  acute  nephritis.  The 
method  of  treatment  usually  advised  for  this  serious 
malady  is  often  very  unsatisfactory  in  its  results. 
Recovery  is  slow,  and  in  a  large  number  of  cases 
imperfect.  In  the  worst  cases,  if  death  from  acute 
suppression  or  rapid  uraemia  does  not  supervene, 
the  patient  passes  into  a  condition  of  chronic  albu- 
minuria and  dropsy,  becoming,  as  my  former  teacher 
the  late  Dr  Moxon  expressed  it,  "  a  large  white  man 
with  a  large  white  kidney."  In  the  majority  of  cases 
more  or  less  albuminuria  remains  after  apparent 
recovery,  and  in  many  there  is  relapse  of  inflamma- 
tion in  the  damaged  organs,  leading  directly  or  in- 
directly to  a  fatal  issue. 

Even    the    etiology    of    acute    nephritis    is    very 


94  ACUTE  NEPHRITIS  [lect. 

imperfectly  understood.  Scarlet  fever  is,  of  course, 
responsible  for  a  very  severe  form  of  nephritis.  Diph- 
theria often  causes  transitory  albuminuria,  more  rarely 
a  real  nephritis.  The  same  may  be  said  of  influenza, 
typhoid  fever,  and  pneumonia.  The  rheumatic  diplo- 
coccus  has  been  found  in  the  urine  of  rheumatic 
patients,  and  it  must,  in  the  future,  be  a  subject  for 
inquiry  whether  an  attack  of  acute  rheumatism  may 
possibly  be  responsible  for  slow  insidious  changes  in 
the  kidney,  whether,  for  instance,  it  may  be  one  of  the 
causes  of  granular  kidney.  The  "  cold  and  wet,"  to 
which  some  cases  of  acute  nephritis  are  ascribed,  pro- 
bably act,  as  they  do  in  the  production  of  pneumonia, 
by  permitting  the  internal  cultivation  of  parasitic 
micro-organisms,  and  the  elimination  of  their  toxins. 
Many  cases  of  subacute  nephritis  in  children  and  young 
adults  arc  difficult  of  explanation  ;  in  many  of  them 
there  has  been  no  ascertainable  exposure  to  cold  and 
wet  or  to  infection  from  scarlet  fever.  Perhaps  some 
may  be  due  to  the  injury  done  to  the  kidneys  by 
microbes  or  microbic  toxins  from  the  alimentary  canal 
eliminated  in  the  urine.  In  the  worst  case  of  nephritis 
that  I  have  seen  in  a  very  young  child  (aged  2h  years), 
the  only  fact  that  could  be  ascertained  which  seemed 
to  offer  any  explanation  was  that  he  had  suffered  from 
an  attack  of  vomiting  and  diarrhoea  which  lasted 
about  a  fortnight.  Soon  after  his  recovery  from  this, 
about  three  weeks  from  its  onset,  he  was  noticed  to 
be   "  growing  fat."     But   this  "  fat "  was   the  dropsy 


III.]  TREATMENT  BY  ICE  95 

of  an  acute  nephritis,  and  his  urine  was  solid  with 
albumen.  He  was  treated  in  the  manner  usually 
advised,  and  after  a  long  and  trying  illness  gradually 
made  a  very  imperfect  recovery.  Considerable  albu- 
minuria remained  when  he  was  discharged  from  the 
hospital.  This  result  is  certainly  not  a  therapeutic 
victory.  Can  we  do  nothing  better  for  such  patients  ? 
I  think  we  can.  The  external  application  of  icebags 
over  the  inflamed  kidneys  in  nephritis  has,  in  several 
cases,  given  me  excellent  results.  I  have  less  experi- 
ence of  the  use  of  ice  in  nephritis  than  in  pericarditis 
or  in  pneumonia,  partly  because  the  cases  are  less 
common,  but  mainly  because  of  the  apprehension, 
only  gradually'  overcome,  that  the  attempt  might 
result  in  a  fatal  suppression  of  urine.  But  in  this 
case  also  time  has  proved  to  me  the  wisdom  of  the  old 
adage,  "  Don't  think  ;  try!'  For  it  has  turned  out  that 
when  used  with  proper  precautions  ice  over  inflamed 
kidneys,  far  from  causing  suppression  of  urine,  is  an 
excellent  diuretic,  rapidly  increasing  the  amount  of 
urine  passed.  No  doubt  there  might  be  danger  of 
inducing  suppression  if  the  ice  were  applied  while  the 
skin  was  dry  and  cold,  and  the  patient  more  or  less 
collapsed.  For  indeed  suppression  may  be  caused  by 
the  disease  itself,  as  I  found  recently  in  the  case  of  a 
woman,  aged  36,  whom  I  saw  in  consultation  a  few 
hours  before  her  death  on  the  sixth  day  of  an  acute 
suppression.  A  catheter  passed  into  the  bladder 
removed   about    an    ounce   of    turbid    urine   full   of 


96  ACUTE  NEPHRITIS  [lect. 

albumen.  No  treatment  had  been  attempted.  But 
if  a  patient  with  nephritis  be  first  made  thoroughly 
warm  and  his  skin  somewhat  moist  by  a  hot-air  bath, 
and  he  be  kept  warm  by  hot-water  bottles,  it  is  quite 
safe  to  apply  icebags  over  his  kidneys.  Not  only  is 
it,  with  such  precautions,  quite  safe,  but  the  result  is 
often  most  satisfactory. 

S.  S.,  a  boy  of  15,  was  admitted  into  St  Mary's 
Hospital  under  my  care  on  9th  May  1903,  for  sub- 
acute nephritis.  The  dropsy  was  slight,  but  the  urine 
was  reddish  in  colour,  containing  blood  and  epithelial 
and  fatty  casts.  It  was  of  specific  gravity  1012,  acid 
in  reaction,  contained  albumen  to  the  amount  of  one- 
fifth,  and  1.5  per  cent,  of  urea.  The  quantity  passed 
in  the  twenty-four  hours  before  treatment  was  begun 
was  34  oz.  A  single  icebag  was  applied  over  the 
right  kidney  only,  without  any  previous  hot-air  bath, 
as  the  boy's  skin  was  warm  and  not  dry.  Directions 
were  given  that  the  quantity  of  urine  passed  in  every 
successive  period  of  eight  hours  should  be  separately 
measured  and  tested.  The  amount  of  urine  on  the 
first  day  of  the  application  of  the  icebag  was  34  oz., 
the  same  amount  as  on  the  previous  day.  On  the 
second  day  of  the  ice  it  increased  to  52  oz.,  on  the 
third  day  it  was  40  oz.,  on  the  fourth  day  again  52  oz. 
Thus  the  average  amount  of  urine  for  the  four  days 
during  which  a  single  icebag  had  been  applied  was 
44  oz.,  an  increase  of  nearly  30  per  cent.  Two  icebags 
were  now  applied,  one  over  each  kidney.  A  further 
marked  increase  in  the  quantity  of  urine  followed 
immediately.  On  the  first  day  of  the  application  of 
two  icebags  the  amount  passed  was  78  oz.,  on  the 
second  day  70  oz.,  on  the  third  58  oz.  Thus  the 
average  amount  for  these  three  days  was  6S  oz.,  an 


in.]  ILLUSTRATIVE  CASES  97 

increase  of  lOO  per  cent.  This  diuresis  was  due  solely 
to  the  ice,  for  no  medicine  was  given.  The  two  bags 
were  retained  in  position  for  ten  days,  with  the  excep- 
tion of  one  period  of  eight  hours,  the  amounts  passed 
during  these  ten  days  being  respectively  78,  70,  58, 
56,  60,  53,  59,  60,  71,  70  oz.,  giving  an  average  of  63.5 
oz.  Thus  the  diuresis  was  steadily  maintained.  The 
quality  of  the  urine  also  progressively  improved.  It 
soon  lost  its  red  colour,  though  some  blood-corpuscles 
could  still  be  seen  when  the  ice  wafs  removed  after 
the  total  period  of  fourteen  days  ;  the  casts  rapidly 
diminished  and  entirely  disappeared,  and  the  amount 
of  albumen  fell  from  about  one-fifth  to  about  one- 
tenth.  The  amount  of  urea  rose  to  2  per  cent.  After 
the  fortnight's  treatment  by  ice  the  boy  was  still  kept 
in  bed  for  five  weeks,  but  no  other  treatment  was  used. 
The  amount  of  albumen  progressively  diminished, 
and  finally  became  only  a  "very  faint  trace." 

Similar  results  have  followed  in  other  cases,  and  it 
is  now  clear  that,  when  used  with  proper  care,  ice 
over  inflamed  kidneys  has  a  well-marked  diuretic 
influence,  by  diminishing  the  local  congestion  in  the 
inflamed  organ,  as  it  lessens  the  congestion  in  an  in- 
flamed appendix  or  in  an  inflamed  lung.  It  appears 
to  be  directly  curative. 

Another  illustration  of  the  diuretic  effect  of  ice 
over  the  kidneys  in  nephritis  may  be  given. 

A  girl,  aged  6,  m  my  ward  at  the  Hospital  for  Sick 
Children,  was  treated  for  nephritis  with  dail}^  hot-air 
baths  and  aperients.  During  eight  days  of  this  treat- 
ment the  amount  of  urine  averaged  16  oz.  She  slowly 
improved,  and  when  she  was  sent  to  a  convalescent 

G 


98  ACUTE  NEPHRITIS  [lect. 

home  the  albumen  was  estimated  at  one-third.  Two 
weeks  later  she  was  readmitted  for  fresh  general 
cedema.  The  amount  of  urine  passed  on  the  first 
day  after  her  readmission  was  only  2  oz.;  on  the 
second  day,  4  oz.  A  single  hot-air  bath  was  given, 
and  then  icebags  were  applied  over  the  kidneys. 
The  amount  passed  on  the  third  day  was  y^  oz. ;  on 
the  fourth  day,  27  oz. ;  on  the  fifth,  37  oz. ;  on  the  sixth, 
36  oz. ;  on  the  seventh,  37  oz.  ;  on  the  eighth,  36  oz. 
The  effect  on  the  albuminuria  was  quite  as  remark- 
able. When  sent  to  the  convalescent  home,  the 
amount  of  albumen  was  estimated  at  one-third. 
When  she  returned,  it  was  one-fourth.  After  four 
days  of  the  icebag,  it  was  only  one-sixth,  and  two  days 
later  there  was  only  a  trace  of  albumen  present. 

One  more  case  may  be  related  which  will  show 
how  useful  the  application  of  ice  may  be  in  a  very 
severe  case  of  nephritis  : 

H.  v.,  aged  3  years  and  10  months,  was  admitted 
into  the  Hospital  for  Sick  Children  on  9th  November 
1 90 1,  having  suffered  from  headache,  shivering,  re- 
peated vomiting  for  seven  days,  swollen  face  for  six 
days,  and  bloody  urine  for  two  days.  On  admission, 
he  was  pale  and  very  restless,  with  a  furred  tongue, 
and  temperature  of  102.8°.  No  urine  at  all  was  passed 
that  afternoon  and  evening.     He  vomited  once. 

lOtk  November. — Urine,  2  oz.,  very  smoky,  contains 
blood  ;  albumen  =  i.    No  casts.    Vomited  three  times. 

wth  November. — Hot-air  bath,  followed  by  two 
leeches  over  each  kidney.  Hot-water  bottles  were 
placed  in  the  bed,  and  two  icebags  were  applied  over 
the  kidneys.  Urine  about  4  oz.  (not  all  saved). 
Vomited  five  times.  In  the  evening  the  icebags  were 
remo\ed  for  four  hours.     Another  hot-air  bath  was 


Ill  J  CASES  TREATED  BY  ICE  99 

given.  The  icebags  were  afterwards  replaced  and 
kept  in  position  all  the  night. 

\2tJi  November.  —  Temperature,  ioi°  to  102.2''. 
Urine,  about  5  oz.  Vomiting  troublesome.  Rectal 
feeding  adopted. 

\ltJi  November. — Child  has  been  very  drowsy  since 
admission  and  restless.  Very  restless  in  the  evening. 
Restlessness  was  increased  by  the  hot-air  bath. 
Temperature  rose  this  afternoon  to  104°,  and  a 
patch  of  dullness  was  found  at  the  right  base,  with 
slight  pleural  friction.  An  icebag  was  placed  over 
the  right  base  as  well  as  over  the  kidneys.  Four 
hours  later,  the  temperature  had  fallen  from  104°  to 
102",  the  pulse  from  128  to  100,  and  the  respirations 
from  50  to  40.  The  child  had  been  sleeping  a  good 
deal.  It  was  observed  that  he  was  much  less  restless 
while  the  iceba-gs  were  in  position,  and  became  more 
restless  when  they  were  removed.  Urine  now  con- 
tains a  few  hyaline  and  corpuscular  casts,  and  abun- 
dant red  cells. 

\Afth  November. — Total  urine  yesterday,  ^\  oz. ; 
albumen,  \.  Still  vomits  anything  but  barley-water ; 
retains  nutrients.  Temperature,  100.3°;  pulse,  100; 
respirations,  36. 

\<itJi  November. — More  than  10  oz.  of  urine  yester- 
day. Friction  at  right  base  now  not  audible,  but 
slight  dullness  remains.  He  is  now  taking  malted 
milk  by  the  mouth,  and  does  not  vomit. 

\6th  November. — Better.  Takes  more  interest  in 
his  surroundings.  More  than  13  oz.  of  urine  yester- 
day. 

I'jth  November. — Last  evening  the  temperature  rose 
to  105.4°,  and  the  amount  of  urine  fell  to  8  oz. 

18///  November. — Urine  yesterday  only  5  oz.  Tem- 
perature, 102.8". 

\gth  November. — Urine  yesterday  more  than  6  oz. 

20th    November.  —    More    than    9    oz.     of    urine. 


100  ACUTE    NEPHRITIS  [lect.  hi. 

The  temperature  fell  last  evening  to  97.6  ,  and  the 
icebags  were  removed  for  eight  hours ;  when  they 
were  reapplied  it  was  100.2'';  at  6  P.M.  it  was  normal. 
Urine  contains  less  blood,  and  shows  few  red  blood- 
cells,  but  many  leucocytes  with  abundant  epithelial 
and  granular  casts. 

2\st  November. — Good  amount  of  urine.  Icebags 
left  off  at  night,  but  replaced  during  the  daytime. 

25///  November. — Urine  in  fair  amount ;  albumen 
much  less.  Icebags  discontinued  altogether,  after 
fourteen  days'  use. 

28//^  November. — Urine  in  fair  amount ;  cannot  all 
be  saved.  It  still  contains  leucocytes  and  granular 
and  epithelial  casts,  but  no  blood,  and  only  a  trace  of 
albumen. 

^tJi  December. — Urine  contains  one  or  two  granular 
casts,  but  no  leucocytes,  no  blood,  and  only  a  trace  of 
albumen. 

lOth  December. — One  or  two  casts.  Only  a  trace 
of  albumen. 

In  conclusion,  I  desire  to  express  my  thanks  to  the 
Council  of  the  Harveian  Society  for  the  honour  of 
delivering  the  Harveian  Lectures  for  1903. 


OTHER    PAPERS 


CASE  OF  MALFORMATldx  OF  THE 
HEART,  WITH  TRANSPOSITION  OF 
THE  AORTA  AND  PULMONARY 
ARTERY. 

{Pathological  Transactions^  1880.) 

The  heart  now  exhibited  to  the  Society  was  taken 
from  a  male  infant,  7  months  old,  who  was  under 
my  care  at  the  Hospital  for  Sick  Children,  Great 
Ormond  Street,  during  the  last  four  months  of  his 
life.  The  child  had  suffered  from  cyanosis  and 
shortness  of  breath  ever  since  its  birth.  When  I  first 
saw  it,  I  found  it  intensely  cyanosed  in  the  head  and 
upper  limbs,  decidedly  less  so  in  the  trunk  and  lower 
limbs.  There  was,  however,  not  the  least  trace  of 
clubbing  ;  the  fingers  tapered  quite  naturally.  The 
heart  was  evidently  large,  and  it  was  beating  rapidly 
(168  in  the  minute) ;  the  second  sound  at  the  base 
was  accentuated,  but  there  was  no  bruit  whatever. 
The  chest  in  general  was  hyper-resonant,  even  down 

to  the  bases  of  the  lungs  posteriorly. 

101 


102         MALFORMATION  OF  THE  HEART 

This  condition  continued  for  two  months.  When 
he  was  5  months  old,  a  bruit  became  developed.  It 
was  systolic,  and  was  best  heard  at  the  left  base  of 
the  heart  and  towards  the  left  clavicle,  also  behind  in 
the  upper  interscapular  region.  Before  the  child's 
death,  however,  it  became  much  less  audible,  and  at 
times  seemed  to  have  vanished. 

At  the  autopsy  it  was  found  that  two  parallel 
vessels  arose  from  the  base  of  the  heart.  The  vessel 
on  the  right  side  was  connected  with  the  right 
ventricle,  and  proved  to  be  the  aorta  ;  it  gave  off  the 
coronary  arteries,  and,  passing  upwards,  gave  origin 
normally  to  the  innominate,  left  carotid,  and  left  sub- 
clavian. It  then  became  narrowed,  and  joined  the 
ductus  arteriosus  to  form  the  descending  aorta.  The 
vessel  on  the  left  side,  taking  origin  from  the  left 
ventricle,  was  the  pulmonary  artery.  It  was  consider- 
ably larger  than  the  aorta.  It  divided  normally  into 
the  two  branches  for  the  lungs,  and  gave  off  a  patent 
ductus  arteriosus.  Judging  from  the  size  of  the 
pulmonary  artery  and  from  the  contraction  of  the 
aorta,  it  would  seem  that  the  two  vessels  had  con- 
tributed about  equally  to  the  supply  of  the  descend- 
ing aorta.  The  right  auricle  received  the  systemic 
veins,  while  the  pulmonary  veins  were  emptied  into 
the  left  auricle.  The  foramen  ovale  was  practically 
closed,  only  a  very  small  oblique  opening  remaining. 
There  was  a  considerable  deficiency  in  the  septum  of 
the    ventricles,   and    the    pulmonary    artery    was   so 


DESCRIPTION  103 

placed  that  its  entrance  was  above  this  opening ;  it 
had  no  doubt  received  blood  from  both  ventricles. 
The  right  ventricle  was  hypertrophied,  its  walls  being 
as  thick  as  those  of  the  left.  The  various  valves  were 
normally  formed  and  placed,  only  the  mitral  showed 
some  slight  but  distinct  thickenings. 

The  effect  on  the  circulation  must  have  been  that 
the  head  and  upper  limbs  received  only  venous  blood, 
while  the  trunk  and  lower  limbs  received  blood  partly 
arterialised.  The  pulmonary  artery  and  veins  must 
have  contained  almost  wholly  arterial  blood.  This 
peculiar  circulation  seems  to  account  for  the  distribu- 
tion of  the  cyanosis,  and  also  for  the  dyspnoea,  the 
respiratory  centre  in  the  medulla  oblongata  being 
furnished  with  none  but  venous  blood.  As  to  the 
etiology  of  the  case,  the  mother  stated  that  when 
about  six  weeks  pregnant  she  was  bathing  at  Hastings 
with  three  other  women,  when  two  of  them  suddenly 
sank,  and  were  rescued  with  great  difficulty.  She 
was  much  frightened,  and  was  ill  the  same  day  with 
repeated  vomiting,  followed  by  diarrhoea.  Whether 
this  be  considered  in  any  way  causal  of  the  child's 
condition  or  not,  it  seems,  at  all  events,  certain  that 
a  strong  impression  was  made  on  the  abdominal 
ganglia  of  the  mother  at  the  time  of  the  formation 
of  the  septa  of  the  heart,  which  embryologists  assign 
as  the  sixth,  seventh,  and  eighth  weeks. 

This  case   seems   to  throw  light    on  the   debated 
question  of  the  causation  of  cyanosis.     It  was  at  one 


104  MALFORMATION  OF  THE  HEART 

time  the  received  opinion  that  cyanosis  was  due  to 
the  intermixture  of  venous  and  arterial  blood,  owing 
to  abnormal  communications  between  the  two  sides 
of  the  heart.  Stille,  however,  showed — ist,  that 
cyanosis  may  exist  without  intermixture  of  the 
currents  of  blood ;  2ndly,  that  there  is  no  just  pro- 
portion between  the  intensity  of  the  cyanosis  and  the 
amount  of  venous  blood  which  enters  the  systemic 
vessels ;  srdly,  that  complete  intermixture  may  take 
place  without  cyanosis  being  produced  ;  and,  4thly, 
that  the  variations  in  the  extent,  depth,  and  duration 
of  the  discoloration  are  inexplicable  by  the  doctrine 
of  the  intermixture  of  the  currents.  He  therefore 
falls  back  upon  the  theory  that  cyanosis  is  due  to 
congestion  of  the  venous  system,  and  points  out  that 
in  fifty-three  cases  out  of  sixty-two  there  was  obstruc- 
tion or  contraction  of  the  pulmonary  artery. 

Dr  Peacock,  in  his  well-known  work  on  malforma- 
tions of  the  heart,  after  a  careful  discussion  of  the 
causation  of  cyanosis,  comes  to  the  same  conclusion. 
He  points  out,  on  the  one  hand,  that  cyanosis  may 
occur  without  any  communication  between  the  two 
sides  of  the  heart,  instancing  especially  the  case  of  a 
cyanotic  girl  in  whom  there  was  an  abnormal  parti- 
tion in  the  right  ventricle  without  any  other  malfor- 
mation ;  and,  on  the  other  hand,  that  abnormal 
communications  arc  often  found,  and  those  not 
merely  narrow,  but  widely  open,  in  cases  where  there 
has  been    no   cyanosis.       Especially   remarkable  are 


THEORIES  OF  CYANOSIS  105 

cases  such  as  that  of  Valleix,  where  the  septum  of  the 
ventricles  was  so  rudimentary  that  a  complete  mixture 
of  the  two  blood-currents  must  have  occurred. 

These  observations  appear  to  be  decisive  against  the 
theory  that  cyanosis  is  pathognomonic  of  the  exist- 
ence of  abnormal  openings  in  the  heart. 

Are  we,  therefore,  obliged  to  fall  back,  as  Stille  and 
Peacock  have  done,  on  the  theory  df  venous  conges- 
tion ?  The  heart  now  exhibited  seems  to  be  an 
answer  to  this  question.  In  this  case,  though  there 
was  intense  cyanosis,  there  can  have  been  no  venous 
congestion.  The  systemic  blood  was  returned  to  the 
right  auricle  and  passed  through  a  normal  auriculo- 
ventricular  opening  into  a  well-formed  and  rather 
hypertrophied  right  ventricle.  From  this  it  had  two 
means  of  exit,  an  aorta  as  large  as  an  ordinary 
pulmonary  artery,  and  quite  unobstructed,  and  in 
addition  a  wide  opening  in  the  septum,  which 
admitted  it  to  probably  quite  one-third  of  a  pulmon- 
ary artery  as  large  as  an  ordinary  aorta.  The  lungs 
also  were  fully  expanded.  There  can,  therefore,  have 
been  no  venous  congestion,  and  a  confirmation  of  this 
is  found  in  the  fact  that  there  was  an  entire  absence 
of  clubbing. 

Hence  in  this  case  the  venous  congestion  theory 
breaks  down. 

Is  there  no  third  theory  which  will  account  for  all 
the  cases  ? 

I    would    suggest    that    cyanosis     simply    means 


106        MALFORMATION  OF  THE  HEART 

deficient  aeration  of  blood,  and  that  the  amount  of 
cyanosis  is  a  measure  of  the  amount  to  which 
aeration  of  the  blood  has  been  hindered.  This  is  by 
no  means  the  abnormal-communication  theory  in 
another  form,  for  one  may  easily  understand  that 
even  a  considerable  intermixture  of  venous  with 
arterial  blood  would  not  reveal  its  presence  if  the 
whole  mass  of  the  blood  were  fairly  aerated,  or  would 
only  cause  slight  occasional  lividity  when  other  diffi- 
culties to  the  circulation  arose,  as  has  been  the  case  in 
several  recorded  instances  of  widely  patent  openings 
and  rudimentary  septa.  On  the  other  hand,  in  such 
cases  as  the  one  before  us  the  circulation  is  perfectly 
free,  but  aeration  must  have  been  very  badly  per- 
formed. The  blood  supplied  to  the  head  and  upper 
limbs  had  not  passed  through  the  lungs  at  all,  and 
some  of  that  which  passed  from  the  right  ventricle 
into  the  pulmonary  artery,  and  by  the  ductus 
arteriosus  into  the  descending  aorta,  must  have  been 
in  the  same  condition. 

Meantime,  the  aerated  blood  from  the  lungs  was 
poured  back  into  the  left  auricle,  and  thence  into  the 
left  ventricle,  to  pass  mainly  into  the  branches  of  the 
pulmonary  artery  once  more,  being  thus  chased  con- 
tinually through  the  pulmonary  circulation  without 
much  chance  of  improving  by  its  admixture  the 
general  mass  of  the  blood. 

This  same  theory,  a  deficiency  in  aeration,  will  I 
think  explain  all  cases  of  cyanosis.     It  will  obviously 


ANALYSIS  OF  CASES  107 

explain  all  the  cases  in  which  there  has  been  con- 
tracted or  obstructed  pulmonary  artery  or  obstruction 
in  the  right  ventricle,  without  abnormal  communica- 
tions, that  is  to  say,  the  cases  which  the  venous  con- 
gestion theory  was  invented  to  explain.  It  is  not  the 
venous  congestion  pure  and  simple,  but  the  congestion 
of  non-aerated  blood,  that  will  account  for  them. 

An  objection  might  be  brought,  thkt  on  this  theory 
cyanosis  should  exist  in  the  cases  of  stenosis  of  the 
pulmonary  valves  in  adults,  but  its  occasional  absence 
here  is  explained  by  the  compensatory  hypertrophy 
of  the  right  ventricle. 

This  theory,  I  repeat,  is  not  the  intermixture  theory 
in  another  form  ;  indeed,  in  one  point  of  view,  it  is 
quite  opposed  to  it,  for,  in  such  a  case  as  the  present, 
to  increase  intermixture  of  blood  would  have  been  to 
improve  the  aeration  of  the  whole  mass,  and  hence  to 
diminish  the  cyanosis.  That  complete  intermixture 
takes  place  in  a  single  ventricle  will  matter  compara- 
tively little  if  each  individual  blood-corpuscle  has  its 
turn  of  oxidation. 

Out  of  Dr  Peacock's  twenty-five  cases  there  are 
only  four  in  which  cyanosis  was  not  present.  One  of 
these  was  a  case  of  stenosed  pulmonary  valves  in  an 
adult,  which  may  not  have  been  congenital.  Of  the 
three  others,  one  was  a  case  of  patent  foramen  ovale 
without  other  defect ;  the  second  had  contraction  of 
the  aorta  with  patent  ductus  arteriosus  ;  whilst  in  the 
third  both    auricles    opened    into   a   single   ventricle, 


108  MALFORMATION  OF  THE  HEART 

which  supplied  the  pulmonary  artery  (the  aorta 
springing  from  an  atrophied  right  ventricle). 

In  all  these  cases  there  can  have  been  no  obstacle 
to  aeration,  and,  accordingly,  there  was  no  cyanosis. 

In  one  case  of  Dr  Peacock's  the  presence  or 
absence  of  cyanosis  is  not  stated.  All  his  other  cases, 
twenty  in  number,  were  cyanotic,  and  in  all  of  them 
there  was  some  obstructive  condition,  either  of  the 
pulmonary  artery  or  of  the  right  ventricle  ;  hence  in 
all  there  must  have  been  imperfect  aeration. 

These  cases,  therefore,  completely  support  the 
theory  above  advanced. 

Clubbing  of  t J le  fingers  and  toes  is  another  symptom 
on  which  this  case  throws  light.  There  was  an  entire 
absence  of  clubbing,  although  the  cyanosis  was 
intense.  Is  it  not  reasonable  to  connect  this  fact  with 
the  absence  of  congestion  of  the  venous  system  ? 

To  test  this,  I  have  again  analysed  Dr  Peacock's 
twenty-five  cases.  In  fourteen  of  the  twenty-five  the 
question  of  clubbing  is  not  referred  to.  Out  of  the 
remaining  eleven,  seven  are  said  to  have  been 
decidedly  clubbed,  three  slightly  clubbed,  and  one 
probably  not  clubbed.  In  all  the  eleven  there  was 
obstruction  on  the  right  side  of  the  heart ;  but 
whereas  in  all  the  seven  clubbed  cases  the  foramen 
ovale  was  closed,  in  all  the  four  cases  slightly  or  not 
at  all  clubbed  the  foramen  ovale  was  open.  This 
seems  to  indicate  pretty  clearly  that  the  clubbing  is 
due  to   congestion    of  the    systemic    veins    in   cases 


CAUSE  OF  CLUBBING  109 

where  the  foramen  ovale  is  closed,  but  that  where 
that  passage  is  open  the  congestion  is  so  much 
relieved  that  clubbing  does  not  result. 

I  will  only  add  a  reference,  by  way  of  confirmation, 
to  Dr  Pye-Smith's  case  of  "  Transposition  of  the 
Aorta  and  Pulmonary  Artery,"  recorded  in  a  previous 
volume  of  the  Transactions  (vol.  xxiii.  p.  80),  which 
much  resembles  my  case,  and  in  whidi  also  there  was 
cyanosis,  but  no  clubbing  ;  and  to  one  reported  by  Dr 
Crocker  last  year,  in  which,  again,  there  was  cyanosis 
without  clubbing,  and  in  which  there  was  found  tri- 
cuspid atresia,  but  the  foramen  ovale  was  widely  open. 

I  submit  that  it  is  thus  fairly  demonstrated  that 
cyanosis  is  due  to  defective  aeration,  and  that  clubbing 
is  due  to  systemic  venous  congestion. 


LARYxNX      FROM      AN  INFANT      WHICH 

HAD      BEEN      THE  SUBJECT     OF     A 

PECULIAR     FORM  OF     OBSTRUCTED 
INSPIRATION. 

{PatJwlogkal  Transactio?is^  1883.) 

The  larynx  now  exhibited  to  the  Society  was  taken 
from  an  infant  of  a  year  old,  which  had,  during  its 
whole  life,  manifested  a  peculiar  noisy  respiration. 
Each  inspiration  was  accompanied  by  a  croaking 
sound,  while  expiration  was  much  less  affected 
(indeed,  usually  entirely  free),  and  the  cry-sound  was 
quite  clear.  About  a  month  before  the  child's  death 
a  laryngoscopic  examination  was  made,  and  it  was 
then  seen  that  the  upper  aperture  of  the  larynx  was 
in  the  form  of  a  narrow  median  slit,  extending  from 
above  downwards,  the  epiglottis  being  folded  on  itself, 
so  that  the  posterior  surfaces  of  its  lateral  halves  were 
almost  in  contact,  and  the  ary-epiglottic  folds  close 
together  and  almost  overlapping.  A  second  ex- 
amination was  attempted  a  month  later,  when 
uu 


Larynx  from  an  Infant  which  had  been  the  subject  of  a 
peculiar  form  of  Obstructed  Inspiration. 


[VdCf  piwc  110. 


ABNORMAL  LARYNX  111 

it  was  observed  that  a  small  white  diphtheritic 
patch  was  present  on  each  tonsil.  The  child  died 
three  days  after  this.  The  drawing  shows  the 
condition  of  the  larynx  as  seen  about  two  days 
after  death. 

The  epiglottis  is  much  curled  inwards,  even  more 
than  it  usually  is  in  infants.  The  aryteno-epiglottic 
folds  are  in  close  proximity  ;  indeed,  they  seem  to 
be  in  actual  contact.  They  were  quite  thin,  and  not 
at  all  oedematous  when  the  specimen  was  obtained. 
Above  them,  below  the  centre  of  the  folded  epi- 
glottis, is  an  opening  of  the  size  of  a  pinhole ;  and 
below  them,  between  the  arytenoid  cartilages,  a 
second  and  rather  larger  opening.  The  vocal  cords 
and  the  rest  of  the  interior  of  the  larynx  were 
healthy.  The  trachea  was  lined  with  diphtheritic 
membrane. 

I  have  seen  four  cases  in  which  this  peculiar  croak- 
ing inspiration  was  present.  i\ll  four  were  girls.  In 
all  the  condition  appeared  to  be  congenital,  and  in  all 
fairly  constant,  except  that  occasionally  exacerbations 
seemed  to  be  caused  by  exposure  to  cold  and  by 
flatulence.  The  croak  is  of  a  lower  pitch  than  the 
crow  of  laryngismus.  It  continues,  though  less  loud, 
during  sleep,  and  after  the  administration  of  chloro- 
form. There  is  usually  some  recession  above  the 
sternum  during  inspiration,  and  slightly  also  at  the 
base  of  the  thorax  ;  but  as  a  rule,  sufficient  air  seems 
to  enter  the  chest. 


112        FORM  OF  OBSTRUCTED  INSPIRATION 

In  at  least  one  of  the  cases,  the  symptom  entirely 
passed  away  as  the  child  grew.  This  is,  I  believe, 
the  first  time  that  the  cause  of  obstruction  has  been 
ascertained  either  by  the  laryngoscope  or  by  post- 
mortem examination. 


TWO  CASES  OF  BRONCHOPNEUMONIA 
TREATED  WITH  BLEEDING  AND  ICE. 

{British  Medical  Journal^  wth  July  1885.) 

Case  I. — Emily  B.,  a  domestic  servant,  aged  15,  but 
looking  older,  came  among  my  out-patients  at  St 
Mary's  Hospital  on  24th  January  1885,  complaining 
of  cough,  shortness  of  breath,  and  sharp,  cutting  pain 
in  the  left  side.  She  had  been  ill  for  about  ten  days, 
and  thought  that  she  had  taken  cold  from  sleeping  in 
a  damp  bed,  having  on  several  occasions  awaked 
during  the  night  to  find  herself  shivering.  I  found 
a  small  area  of  dullness  in  the  second  left  interspace 
in  front,  and  rales  over  the  greater  part  of  the  left 
lung,  and  also  at  the  base  of  the  right.  There  was 
much  dyspnoea,  and  the  temperature  was  above  104°. 
By  the  kindness  of  Dr  Cheadle,  I  was  enabled  to 
admit  her  into  the  hospital  under  my  own  care.  She 
was  at  once  put  to  bed,  and  hot  poultices  applied  to 
the  chest. 

2^th  January. — She   had   slept   fairly   during   the 
night,  but  this  morning  had  much  distress  in  breath- 

113  ^ 


lU     TWO  CASES  OF  BRONCHOPNEUMONIA 

ing.  The  dyspnoea  was  very  obvious.  There  was 
restlessness ;  the  lips  were  livid,  and  the  cheeks 
dusky.  Temperature,  105°;  pulse,  136,  regular,  and 
fairly  strong ;  respirations,  44.  The  urine  was  of 
specific  gravity  1030;  it  contained  urates,  but  no 
albumen  ;  chlorides  were  present.  The  bowels  had 
not  been  opened  during  the  last  four  days.  The 
sputum  was  copious,  viscid,  not  rusty.  There  was 
dullness  over  the  whole  of  the  front  of  the  left  side 
of  the  chest  to  the  nipple-level  ;  the  breathing,  how- 
ever, being  simply  harsh,  and  not  tubular.  Resonance 
was  somewhat  impaired  below  the  angle  of  the  scapula 
on  both  sides  ;  and  at  both  bases,  in  front  and  behind, 
was  an  abundance  of  moist  rdles^  heard  during  expira- 
tion as  well  as  during  inspiration.  These  physical 
signs,  combined  with  the  high  temperature,  seemed 
to  denote  a  severe  bronchitis  extending  to  the  smaller 
tubes,  with  commencing  consolidation  of  the  left  upper 
lobe.  Taken  with  the  symptoms  of  great  dyspnoea 
and  lividity,  they  seemed  to  render  it  necessary  at 
once  to  give  relief  to  the  overstrained  right  heart, 
without  waiting  for  the  slower  action  of  purgatives 
and  emetics.  Venesection  was,  therefore,  performed 
at  II  A.M.,  10  oz.  of  very  dark  blood  being  drawn 
off.  The  relief  to  the  dyspnoea  was  immediate,  mani- 
festing itself  even  while  the  blood  was  flowing ;  and 
the  lips  lost  their  blueness.  An  enema  was  adminis- 
tered, after  which  the  bowels  were  opened  twice.  At 
12.30  P.M.,  the  temperature  had  fallen  to   103.6'',  the 


TREATED  WITH   BLEEDING  AND  ICE      115 

pulse  remaining  at  136,  and  the  respirations  still 
in  number  44,  but  much  quieter.  The  patient  felt 
much  more  comfortable.  At  9  P.M.,  the  temperature 
was  again  105°  ;  but  the  lips  were  red,  and  the 
dyspnoea  had  not  returned.  An  emetic  was  ordered, 
to  clear  the  bronchial  tubes  of  the  very  copious 
secretion,  and  a  mixture,  containing  10  drops  of 
antimonial  wine,  and  10  gr.  of  bicarbonate  of  soda, 
with  half  an  ounce  of  liquor  ammoniae  acetatis,  to  be 
taken  every  four  hours. 

26tJi  January. — She  was  relieved  by  the  emetic, 
and  had  slept  fairly  well.  The  cough  was  less  trouble- 
some ;  the  lips  were  rather  more  blue  again,  and  the 
cheeks  somewhat  dusky.  Temperature,  105.6' ;  pulse, 
144;  respirations,  48.  The  right  side  of  the  chest 
was  forcibly  expanded  during  inspiration,  especially 
in  its  upper  part.  The  left  front  was  dull  from  the 
clavicle  to  the  nipple-level,  with  bronchial  breathing 
under  the  clavicle.  There  was  dullness  also  about 
the  posterior  edge  of  the  left  scapula.  At  both  bases, 
rales  were  heard  as  before.     The  heart  was  normal. 

It  was  obvious  that,  though  the  immediate  urgency 
had  been  met,  the  pulmonary  symptoms  were  advanc- 
ing in  gravity.  It  was  therefore  determined  to  give 
up  the  poultices,  which  had  been  used  for  two  days, 
and  to  try  the  effect  of  cold  applications.  Directions 
were  given  that  the  patient  should  be  sponged,  first 
with  tepid  and  then  with  cold  water.  This  change 
proving   pleasant  to  her,  an  icebag  was   applied    to 


116     TWO  CASES  OF  BRONCHOPNEUMONIA 

the  left  chest  at  3  P.M.  Immediate  benefit  seemed 
to  follow.  At  8  P.M.  she  looked  tranquil  and  easy ; 
the  lips  were  redder ;  the  temperature  had  fallen  a 
degree  and  a  half  (to  104') ;  and  the  frequency  of  the 
pulse  had  lessened  by  28  beats  per  minute,  being  now 
only  116.  The  respirations  were  still  46  per  minute, 
but  without  marked  dyspnoea.  The  physical  signs 
also  had  improved,  there  being  now  fair  resonance 
from  the  clavicle  to  the  second  rib.  From  the  second 
rib  to  the  mamma  there  was  still  dullness,  with 
bronchial  breathing,  and  coarse  rale  during  inspiration 
only.  At  the  right  anterior  base  there  was  still  moist 
rale  to  be  heard,  during  both  inspiration  and  expira- 
tion.    Pain  in  the  left  side  continued. 

27//^  Jajiuary. — The  icebag  had  been  kept  on  all 
the  night.  Slight  delirium  was  observed  early  this 
morning.  The  temperature  had  fallen  continuously, 
and  at  5  o'clock  this  morning  was  only  98".  After 
8  A.M.,  however,  it  rose  again,  and  at  4  P.M.  stood  at 
105.8',  the  highest  temperature  throughout  the  illness. 
Pulse,  126;  respirations,  40.  I  found  that  the  left  apex 
was  still  improving,  the  resonance  having  now  reached 
as  low  as  the  third  rib  ;  and  over  this  area  the  breath- 
ing was  fairly  normal,  only  the  expiration  a  little 
prolonged.  There  was  still  dullness  from  the  third 
rib  downwards,  but  the  breathing  over  it  was  less 
harsh,  and  there  were  expirator}'  as  well  as  inspiratory 
rales.  There  were  still  moist  sounds  at  the  right 
base  as  before.     So  far  there  was  improvement,  but 


FIRST  CASE  117 

the  rise  of  temperature  was  accounted  for  by  the  dis- 
covery of  fine  inspiratory  crepitation  at  the  angle  of 
the  left  scapula,  and  bronchial  breathing  in  the  axilla. 
Obviously  a  fresh  portion  of  lung  had  been  attacked. 
The  icebag  was  continued,  and  senega  substituted 
for  the  antimonial  wine, 

2Zth  January. — The  temperature  had  again  fallen 
to  98°,  and  the  pulse  to  82.  The' respirations  still 
numbered  44.  The  dullness  was  now  limited  to  a 
small  area  at  the  anterior  border  of  the  left  axilla, 
over  which  loud  moist  rales  were  heard,  with  hardly 
any  bronchial  breathing.  There  was  diarrhoea  yester- 
day, the  bowels  being  opened  twelve  times,  and  she 
vomited  after  the  medicine,  which  was  therefore 
changed  to  quinine.  At  2  P.M.,  the  temperature 
began  to  rise  again,  but  the  highest  point  which  it 
attained  was   103''. 

2gtJi  January.  —  Temperature,  98"';  pulse,  108; 
respirations,  36.  She  was  taking  food  well.  In  the 
afternoon  there  was  another  (and  final)  rise  of  tem- 
perature to  104.2^'.  I  found  that  the  signs  on  the  left 
side  were  still  improving,  but  there  was  now  dullness 
in  the  first  interspace  on  the  right  side,  which  had 
hitherto  been  quite  normal,  and  harsh  inspiration  as 
low  as  the  second  rib.  It  seemed  as  if  the  right  lung 
were  about  to  follow  the  example  of  the  left.  Another 
icebag  was  at  once  applied  to  the  right  apex.  To 
my  surprise,  I  found  next  day  (30th  January)  the 
right  apex   perfectly   normal,   with   good    resonance 


118     TWO  CASES  OF  BRONCHOPNEUMONIA 

and  natural  breathing.  Pulse,  84 ;  respirations,  42  ; 
temperature,  967^ 

On  the  31st  the  temperature  was  98.4'',  at  or  about 
which  it  remained  ;  the  pulse,  84 ;  respirations,  36. 
There  remained  only  some  slight  impairment  of 
resonance  over  the  left  lung  posteriorly,  and  the 
catarrhal  sounds  had  quite  disappeared. 

From  this  time  convalescence  was  uninterrupted, 
and  when  I  examined  her  chest,  before  her  departure 
for  a  convalescent  home,  I  found  ever}'thing  perfectl}- 
normal. 

Case  II. — On  3rd  February  1885,  I  was  asked  to 
see,  in  consultation  with  Dr  Langston,  of  Westminster, 
a  female  infant  aged  6h  months.  She  had  been 
seriously  ill  for  two  days,  and  had  had  a  slight  cough 
for  several  days  previously.  She  was  believed  to 
have  taken  cold  from  exposure  to  cold  winds.  The 
temperature  was  103.4  .  There  was  some  active  dis- 
tension of  the  ala^  nasi,  with  cough,  which  was 
evidently  painful.  On  examining  the  chest,  we  found 
that  there  was  only  very  slight  impairment  of  reson- 
ance over  the  right  back,  with  dryish  j^d/es  over  the 
upper  lobes  behind,  and  a  good  deal  of  moist  rd/es 
over  the  bases,  both  before  and  behind.  We  directed 
that  a  large  turpentine-stupe  should  be  applied  to  the 
chest,  to  Le  followed  by  the  use  of  linimentum  tere- 
binthina:^,  and  that  a  bronchitis-kettle  should  be  kept 
constantly  on  the  fire,  the  temperature  of  the  room 
being   maintained    at   65'    F.      By   the   mouth,    she 


SECOND  CASE  119 

had  been  taking  milligramme-granules  of  aconitinc 
and  of  scillitine  ;  these  were  now  exchanged  for  similar 
granules  of  iemetine. 

Afth  February. — Temperature,  103.5"  (^^^t  night, 
104).  There  was  now  decided  dullness  over  the  root 
of  the  right  lung,  with  bronchial  breathing  and  sharp 
rdles.  Loud  normal  breathing  was  heard  over  the 
left  lung,  with  sorne  moist  rdlcs  at  the  left  base.  She 
was  ordered  to  continue  the  emetine,  and  to  have 
large  mustard  and  linseed  poultices. 

^th  February^  7  P.M. — Temperature  this  morning, 
103.5",  now  104°.  The  child  had  been  very  restless 
to-day,  and  cyanosed.  During  the  afternoon,  it  was 
said  to  have  teen  "  quite  black  "  around  the  mouth. 
Even  by  artificial  light,  it  was  easy  to  see  that  the 
face  was  dusky.  The  respirations  were  exceedingly 
hurried.  On  careful  counting,  there  were  found  to  be 
28  inspirations  in  fifteen  seconds,  or  112  in  the 
minute.  The  heart's  action  was  comparatively  slow, 
very  little  more  than  100  per  minute.  Over  the 
right  ventricle,  the  second  sound  was  loudly  accentu- 
ated ;  and  even  amidst  the  noisy  inspirations,  of 
about  the  same  frequency  as  the  cardiac  action,  the 
thud  of  the  pulmonary  valves  could  be  clearly  heard. 
It  was  evident  that  the  strain  on  the  right  ventricle 
was  rapidly  becoming  more  than  it  could  bear,  and 
that,  unless  immediate  relief  were  afforded,  many 
hours  would  not  elapse  before  arrest  of  its  action 
would  result.     Three  leeches  were  immediately  sent 


120     TWO  CASES  OF  BRONCHOPNEUMONIA 

for.  Meanwhile,  the  child  was  placed  in  a  tepid  bath 
rapidly  cooled.  It  remained  in  the  bath  for  five 
minutes,  but  the  effect  was  to  raise  the  rectal  tempera- 
ture from  104°  to  105°.  Probably,  a  reduction  of 
temperature  would  have  followed  a  longer  immersion  ; 
but,  the  leeches  having  arrived,  they  were  immediately 
applied  over  the  sternum.  They  took  well,  and  the 
bleeding  was  afterwards  encouraged  by  a  poultice. 
It  was  estimated  that  the  amount  of  blood  drawn  off 
was  about  an  ounce,  which  may  be  considered  equiva- 
lent to  a  moderate  venesection  in  the  adult.  It  was 
very  interesting  to  watch  the  immediate  relief  which 
followed.  Even  while  the  leeches  sucked,  the  breath- 
ing became  much  slower  and  deeper;  indeed,  the 
frequency  of  respiration  sank  to  the  rate  of  50  per 
minute,  less  than  one-half  of  its  former  amount.  The 
pulse,  on  the  other  hand,  became  more  rapid,  and 
was  noted  to  be  fully  120.  An  hour  later,  the 
respirations  numbered  between  60  and  70,  and  the 
pulmonary  second  sound  was  found  to  be  much  less 
accentuated.  The  emetine  was  discontinued,  and  it 
was  determined  to  lay  aside  the  poultices,  and  try 
the  effect  of  external  cold.  An  icebag  was  therefore 
laid  over  the  upper  posterior  right  chest,  and  directions 
were  given  that  milk  or  broth  should  be  administered 
(without  stimulants),  and  the  temperature  taken 
every  hour. 

6tJi  February. — The  child  had  slept  fairly,  and  the 
cough  was  less  troublesome.     She  had  taken  nourish- 


RELIEF  BY  LEECHES  121 

ment  well,  sucking  the  bottle  strongly,  which  on  the 
previous  day  she  quite  refused.  The  temperature 
had  been  over  104"  all  night,  and  for  three  hours  was 
I05^  The  lips  and  cheeks  were  still  decidedly  dusky, 
but  nothing  like  so  much  so  as  the  day  before.  The 
father  said  he  "  would  hardly  have  noticed  it  to-day." 
The  heart  seemed  now  to  have  quite  recovered  itself ; 
there  was  no  accentuation  of  the  p'ulmonary  second, 
and  the  action  was  much  more  frequent,  nearly  200  in 
the  minute.  The  respirations  were  about  80.  There 
was  less  dullness  over  the  inner  margin  of  the  scapula, 
but  perhaps  a  little  extension  of  dullness  outwardly, 
and  over  this  spot  were  some  sharp  rales.  During 
the  day  the  temperature  fell  till  it  reached  10 1.7', 
when  the  icebag  was  removed  according  to  instruc- 
tions. Next  day  (7th  February)  it  was  noted  that 
there  was  distinctly  less  dullness  over  the  scapula,  but 
that  at  its  outer  edge  the  rales  persisted.  The  left 
lung  was  now  absolutely  normal.  In  the  evening, 
the  thermometer  again  marked  103",  and  the  icebag 
was  re-applied,  but  was  soon  removed,  as  the  child 
was  thought  to  be  restless  under  it.  The  temperature, 
however,  had  fallen  to  102.6''  in  the  morning  of  the 
8th,  and  to  102"  in  the  evening. 

(jth  b^ebruary. —  The  temperature  was  now  only 
100.3'.  The  colour  was  much  improved,  no  longer 
dusky.  The  cough  was  looser.  The  child  lay 
quietly. 

\otk   February. — A    sudden    accession    of  pyrexia 


122     TWO  CASES  OF  BRONCHOPNEUMONIA 

had  occurred,  the  thermometer  standing  at  105.6". 
There  were  no  new  signs  in  the  right  lung,  but  a 
patch  of  dullness  with  harsh  breathing  was  now  found 
over  the  root  of  the  left  lung,  which  for  the  last  two 
days  had  been  normal.  There  were  also  sharpish 
rales  at  the  angle  of  the  left  scapula.  Respirations, 
70;  pulse,  170.  The  alse  nasi  were  again  working 
freely.  There  was  no  stress  on  the  pulmonary 
second  sound.  The  icebag  was  re-applied,  and  an 
immediate  fall  of  temperature  followed.  At  8.45 
A.M.,  when  the  ice  was  again  applied,  it  stood  at 
105.4° ;  at  10.30  A.M.,  102.6°  (a  fall  of  3°  in 
less  than  two  hours);  at  12.30  P.M.,  101.6°;  at  2.30, 
100°;  at  4.30  P.M.,  98.8°;  at  9.30  P.M.,  101°.  It  was 
directed  that  the  ice  should  be  used  whenever  the 
thermometer  marked  102°. 

\2th  February. —  Morning  temperature,  103.4°. 
There  was  now  fresh  dullness  over  the  left  apex 
posteriorly,  with  harsh  breathing.  Evening  tempera- 
ture, 101°. 

13//J  February. — At  3.30  A.M.,  the  thermometer 
suddenly  rose  to  106°.  The  icebag  was  re-applied, 
and  a  rapid  reduction  followed.  At  9  A.M.,  it  was 
only  102.4°;  pulse,  170;  respirations,  60.  The  child 
seemed  fairly  comfortable,  and  inclined  to  play  with 
a  watch  held  in  front  of  it.  The  dull  spot  at  the  left 
apex  had  now  quite  cleared  up,  but  there  was  a 
finger-tip  area  of  dullness  behind  the  edge  of  the  left 
scapula.     The  rales  had  nearly  disappeared. 


RELIEF  BY  THE  ICEBAG  123 

i^th  Februmy. — The  physical  signs  in  the  lungs 
had  now  quite  disappeared,  but  the  temperature 
continued  to  be  high  (morning,  101.5° ;  evening,  104'). 
This  proved  to  be  due  to  the  co-existence  of  internal 
otitis,  resulting  in  posterior-basic  meningitis.  At  all 
events,  many  of  the  symptoms  of  that  disease  were 
present.  Under  vigorous  treatment,  including  para- 
centesis of  the  tympanic  membran'es,  these  symptoms 
entirely  passed  awa)^ ;  and,  after  an  illness  of  seven 
weeks,  the  child  recovered  perfectly,  and  has  since 
remained  well. 

I  reserve  for  a  subsequent  communication  the 
details  of  the  later  part  of  the  case,  which  are  of 
great  interest,  my  object  at  present  being  simply  to 
discuss  the  treatment  of  the  pneumonia.  But  to 
prevent  any  misapprehension,  it  will  be  well  to  add 
that  the  first  symptoms  of  the  otitis  were  present 
before  the  icebag  was  first  used.  The  aural  inflamma- 
tion vvas  a  part  of  the  original  catarrh ;  and  I  have 
seen  several  cases  in  which  a  similar  otitis  of  catarrhal 
origin  (sometimes  with,  sometimes  without,  accom- 
panying bronchitis  or  pneumonia)  has  caused  death 
by  producing  posterior-basic  meningitis.  But  for 
further  details  on  this  subject,  I  must  refer  to  a 
forthcoming  paper  by  my  colleague,  Dr  Barlow,  and 
myself. 

Remarks. —  The  true  indication  for  bleeding  in 
pneumonia  seems  to  be  the  approach  of  failure  of  the 


124     TWO  CASES  OF  BRONCHOPNEUMONIA 

right  heart  to  overcome  the  greatly  increased  pressure 
in  the  pulmonary  artery,  due  either  to  extensive 
consolidation  of  lung,  or  to  overwhelming  engorge- 
ment. Evidence  of  this  approaching  failure  was 
present  in  each  of  the  cases  above  narrated.  In  the 
former,  the  necessity  for  bleeding  was  in  my  opinion 
urgent ;  in  the  latter,  it  was  not  urgent  but  imperative. 
In  both,  the  relief  afforded  was  marked  and  immedi- 
ate. It  is  doubtful,  however,  whether  it  would  in 
either  case  have  been  more  than  temporary,  but  for 
the  beneficial  influence  of  the  cold  applications.  The 
superiority  of  the  icebag  to  the  poultices  which  it 
replaced  was  very  obvious  in  each  case.  The  older 
patient  was  conscious  of  increase  of  comfort  during 
its  use,  and  the  application  was  therefore  continuous, 
both  by  day  and  by  night.  In  the  case  of  the  baby, 
the  ice  was  removed  when  the  temperature  sank  to 
102",  and  replaced  when  a  further  rise  occurred. 

Conclusion  of  the  second  case,  as  reported  in  the 
Practitioner,  August  1886: — 

The  child  seemed  fairly  comfortable,  and  inclined 
to  play  with  a  watch  held  in  front  of  it.  In  spite  of 
this,  however,  there  were  some  fresh  symptoms  which 
caused  alarm.  The  head  was  observed  to  be  retracted, 
and  on  careful  observation  it  was  noticed  that  the 
respiration  was  distinctly  tending  to  the  Cheyne- 
Stokes  type,  exhibiting  maxima  and  minima  of 
frequency,  with  a  long  slow  ascent  and  descent.     The 


OTITIS  AND  MENINGITIS  125 

retraction  of  the  head  was  not  absolutely  new,  for  I 
had  observed  that  it  was  present  to  a  very  slight 
degree  nine  days  previously,  and  accompanied  by 
some  stiffness  of  the  dorsal  muscles,  so  that  it  was  on 
that  day  (4th  Feb.)  difficult  to  make  the  child  sit  up 
for  examination  of  its  chest.  The  next  day,  however, 
these  symptoms  had  vanished,  and  no  other  indication 
of  meningeal  trouble  was  noticed  u'ntil  the  13th.  The 
temperature  continued  high,  about  104^  in  the  even- 
ing and  102'  in  the  morning.  Two  days  later  (15th 
Feb.)  other  symptoms  of  meningitis  showed  them- 
selves. There  was  occasional  slight  strabismus,  each 
eye  at  times  diverging  a  little.  The  pupils  were 
equal,  but  contracted  (about  i  J  mm.).  Slight  involun- 
tary jerks  of  the  forearms  and  hands  were  noticed. 
The  fontanelle  was  distinctly  too  full  and  tense. 
Retraction  of  the  head  persisted.  Vomiting  had 
occurred  once,  but  only  once,  and  the  bowels  were 
not  constipated.  The  nurse  had  observed  sighing 
several  times  during  the  last  three  days,  also  occasional 
flushing  of  the  face.  For  several  days  also  the  child 
had  persistently  raised  her  left  hand  to  the  side  of 
her  head.  She  now  lay  in  a  semi-comatose  condition, 
hardly  taking  any  notice  of  surrounding  objects.  The 
eyelids  did  not  close  when  the  cornea  was  threatened 
by  the  finger  until  it  was  almost  touched,  but  they 
closed  when  a  bright  light  was  brought.  On  examina- 
tion of  the  gums  the  two  lower  central  incisors  could 
be  felt,  but  they  were  not  pressing  on  the  gum,  and 


126     TWO  CASES  OF  BRONCHOPNEUMONIA 

the  child  had  not  showed  any  sign  of  irritation  in  the 
mouth.  It  was  clear  to  me  now  that  the  catarrh  had 
extended  up  the  Eustachian  tube  into  the  tympanic 
cavity  in  one  or  both  ears,  and  that  the  resulting 
otitis  had  started,  or  was  on  the  brink  of  starting,  a 
basal  meningitis.  My  experience  at  the  Hospital  for 
Sick  Children  has  taught  me  that  a  form  of  simple 
basal  meningitis  affecting  mainly  the  posterior  part 
of  the  base  of  the  brain,  the  territory  supplied  by  the 
vertebral  arteries,  is  of  rather  frequent  occurrence  in 
infants,  and  that  when  an  opportunity  for  post-mortem 
examination  occurs,  muco-pus  is  frequently  found  in 
the  tympanic  cavities. 

I  will  not  enter  into  details  about  this  form  of 
meningitis,  as  I  hope  shortly  to  publish  some  observa- 
tions on  the  subject  conjointly  with  my  friend  and 
colleague  Dr  Barlow ;  *  but  I  may  add  that  the  otitis 
is  frequently  a  result  of  a  previous  catarrh,  which 
has  spread  upwards  along  the  Eustachian  tubes. 

On  this  occasion  I  explained  to  the  parents  that 
there  was  probably  a  collection  of  muco-purulent 
material  pent  up  behind  the  tympanic  membranes, 
which  was  exciting  an  inflammation  of  the  brain,  and 
advised  that  paracentesis  of  the  drum-membranes 
should  be  immediately  performed.  They  consented 
readily,  and  my  colleague  Mr  Field,  Aural  Surgeon  to 

*  Vide  "Simple  Meningitis  in  Children,"  by  D.  B.  Lees, 
M.D.,  and  T.  Badow,  ^\.V>.—Allbutfs  System  of  Medicine,  vol. 
vii.,  pp.  492-559- 


RELIEF  BY  PAHACENTESIS  TYMPANl       127 

St  Mary's  Hospital,  performed  the  operation  on  both 
ears,  an  hour  or  two  later.  Some  blood  flowed  on 
each  side,  but  no  pus  could  be  seen.  A  poultice  was 
then  applied  to  each  ear,  and  an  icebag  to  the  nape 
of  the  neck.  Two  grains  of  iodide  of  potassium  were 
ordered  to  be  given  every  two  hours,  and  mercurial 
ointment  to  be  rubbed  into  the  skin  twice  daily. 

Almost  immediately  after  the  operation  the  child 
was  observed  to  hold  her  head  more  erect,  and  two 
days  later  the  retraction  had  entirely  passed  away, 
the  fontanelle  was  less  tense,  the  pupils  dilated  on 
shading,  and  the  eyes  moved  conjointly.  Evening 
temperature,  102°.  The  respiration,  however,  had  not 
quite  lost  its  Cheyne-Stokes  character.  On  examina- 
tion of  the  chest,  some  slight  loss  of  resonance  still 
remained  over  the  right  scapula,  and  a  few  moist  rales 
could  be  heard.  A  leech  was  applied  behind  each 
ear. 

For  ten  days  after  the  operation  she  improved,  and 
the  cerebral  symptoms  entirely  vanished.  On  25th 
February  she  had  an  attack  of  obvious  earache  in  the 
left  ear,  with  drawing  up  of  the  left  shoulder.  She 
tore  off  the  cotton-wool  that  had  been  placed  over  the 
ear. 

A  minute  dose  of  morphia  relieved  her  and  gave 
her  a  good  night's  rest,  but  the  earache  recurred  two 
days  later.  The  following  night  there  was  a  sudden 
attack  of  dyspnoea,  and  the  day  after  this  I  found  the 
child  again  semi-comatose,  with  diverging  eyes,  and 


128     TWO  CASES  OF  BRONCHOPNEUMONIA 

marked  and  frequent  spasmodic  contractions  of  the 
facial  muscles,  and  of  the  arms  and  hands. 

Mr  Field  was  again  called  in,  and  paracentesis  of 
each  drum-membrane  was  again  performed  ;  fourteen 
days  having  elapsed  since  the  first  operation.  After 
the  incisions,  Politzer's  inflation  of  the  tympanic  cavi- 
ties was  practised,  and  a  little  undoubted  pus  was 
thus  expelled  from  the  left  ear,  blood  alone  flowing 
from  the  right. 

The  poultices  to  the  ears  were  repeated,  but  all  other 
treatment  omitted.  The  ears  were  irrigated,  and 
Politzer's  inflation  practised  daily.  For  the  second 
time  the  cerebral  symptoms  vanished  almost  immedi- 
ately after  the  operation,  and  fortunately  they  did  not 
return. 

Small  flakes  of  lymph-membrane  appeared  for 
several  days  when  the  left  ear  was  irrigated,  and 
once  a  piece  of  considerable  size  for  the  small  cavity 
from  which  it  came.  A  week  after  the  second  opera- 
tion all  discharge  had  ceased,  but  pain  in  the  ears 
recurred,  and  the  temperature  again  rose  to  103.8°. 
Three  drops  of  a  5  per  cent,  solution  of  cocaine  were 
dropped  into  each  ear,  but  no  obvious  benefit  resulted. 
On  the  following  day  the  gums  were  lanced  over  the 
lower  incisors,  which  were  now  more  prominent,  and 
the  instillation  of  cocaine  was  repeated.  Next  day 
the  child  looked  collapsed,  with  a  pale  face,  and  eyes 
half  closed.  Whether  the  cocaine  was  or  was  not 
responsible  for  this,  it  is  certain  that  she  had  not  been 


PARACENTESIS  REPEATED  129 

in  this  collapsed  condition  before  the  cocaine  was 
used.  By  frequent  administration  of  small  doses  of 
brandy  and  Brand's  essence,  she  gradually  revived. 
The  earache  continued.  It  was  partially  relieved  by 
the  instillation  of  a  drop  of  the  liquor  atropinae  sul- 
phatis  into  each  ear,  but  on  subsequent  days  this  treat- 
ment proved  ineffectual,  and  more  permanent  relief 
was  obtained  by  washing  out  the  ep-r  with  warm  water 
containing  a  little  laudanum. 

Eighteen  days  after  the  second  operation  the  left 
lower  central  incisor  appeared,  and  it  was  noted  that 
there  had  been  hardly  any  earache  for  a  day  or  two. 
The  child  sat  up  in  bed  and  played  with  her  toys. 
Three  days  after  this,  she  was  flushed  on  her  right 
cheek  and  about  the  right  ear.  The  gum  was  found 
to  be  hard  over  the  right  lower  central  incisor  ;  it  was 
lanced,  and  the  next  day  this  tooth  emerged.  After 
this,  convalescence  was  uninterrupted.  The  total 
duration  of  the  illness  was  seven  weeks. 

Five  months  later  (15th  August)  she  was  brought 
to  me  for  inspection.  She  appeared  in  perfect  health  ; 
it  was  impossible  to  detect  any  evil  result  from  the 
long  and  severe  illness  through  which  she  had  passed. 
She  was  now  thirteen  months  old,  could  sit  up  naturally 
or  crawl  on  the  floor,  was  quite  intelligent,  and  heard 
perfectly  well  on  both  sides.  Fontanelle  and  circum- 
ference of  head  of  normal  size  for  her  age. 

I  know  that  she  has  continued  up  to  the  present 
time  (July  1886)  in  perfect  health. 

I 


130     TWO  CASES  OF  BRONCHOPNEUMONIA 

Remarks. — I  think  it  may  fairly  be  claimed  that  the 
life  of  this  child  was  four  times  saved  by  treatment, 
once  by  the  leeches,  a  second  time  by  the  icebag, 
and  twice  by  puncture  of  the  tympanic  membranes. 
The  leeches  assuredly  rescued  her  from  imminent 
death ;  without  them,  she  could  scarcely  have  lived 
many  hours  longer.  The  recurrence  of  the  inflamma- 
tion, however,  would  probably  have  brought  her  again 
into  a  similar  condition  of  peril  but  for  the  great 
relief  given  by  the  external  application  of  ice.  I  was 
encouraged  to  adopt  this  treatment  from  observation 
of  the  immediate  and  striking  benefit  I  had  obtained 
from  it  in  a  case  of  bronchopneumonia  in  a  young 
woman  who  had  shortly  before  this  been  under  my 
care  at  St  Mary's  Hospital.  Within  the  last  few  days 
I  have  had  another  illustration  of  its  usefulness  in  the 
case  of  my  own  youngest  child,  who,  with  a  tempera- 
ture of  104',  severe  bronchial  catarrh,  and  lips  already 
growing  dusky,  began  immediately  to  improve  when 
an  icebag  was  applied  to  the  back  of  his  chest,  and 
in  a  few  hours  was  quite  out  of  danger. 

With  regard  to  the  paracentesis,  each  operation 
cut  short  the  cerebral  symptoms  in  the  most  striking 
way.  An  experience  of  many  cases  enables  me  to 
state  with  some  confidence  what  would  have  happened 
if  meningitis  had  been  allowed  to  run  its  course.  The 
head-retraction  would  have  become  more  pronounced, 
the  condition  of  stupor  permanent,  and  convulsions  or 
tonic  spasms  might  have  supervened.     Death  would 


REMARKS  131 

probably  have  resulted  ;  but  if  an  apparent  recovery 
had  occurred,  such  recovery  would  only  too  probably 
have  been  found  to  be  incomplete,  and  a  gradual  in- 
crease of  the  cranial  circumference  would  have  betrayed 
the  existence  of  chronic  hydrocephalus.  Even  if  life  re- 
mained, reason  would  undoubtedly  have  been  impaired, 
and  the  child  might  have  proved  little  better  than  an 
idiot.  From  such  mournful  alternatives  of  fate  she  was 
promptly  rescued  by  the  perforation  of  the  drum- 
membranes.  I  have  notes  of  two  other  cases  in  which 
the  same  happy  result  has  followed  this  operation. 
In  many  other  instances  it  has  been  ineffectual,  I  think 
usually  because  it  has  been  too  late :  in  out-patient 
practice  the'  children  are  often  not  brought  to  the 
hospital  until  the  retraction  of  the  head  has  lasted  a 
week  or  longer. 

P.S. — January  1904.  This  patient  is  now  a  girl 
of  nineteen,  healthy,  intelligent,  and  with  normal 
hearing. 


PRESYSTOLIC  APEX-MURMUR  DUE  TO 
AORTIC  REGURGITATION. 

{American  Journal  of  the  Medical  Sciences^  1890,) 

Case  I. — Henry  H.,  aged  21  years,  was  admitted 
into  St  Mary's  Hospital,  under  the  care  of  Sir  E. 
Sieveking,on  30th  April  1887,  suffering  from  extreme 
anaemia  after  severe  and  repeated  epistaxis.  The 
notes  of  his  case  were  taken  by  Mr  O.  E.  Higgens, 
M.A.  He  had  had  chorea  nine  years  before,  and 
rheumatic  fever  six  years  before  ;  he  was  then  told 
that  his  heart  was  affected.  After  his  recovery  he 
seemed  in  good  health,  and  was  able  to  work  hard  ; 
for  ten  months  he  worked  as  a  navvy  on  a  railway  in 
Canada.  During  the  last  two  years  he  had  been  a 
French  polisher,  and  had  found  no  difficulty  in  doing 
his  work  until  lately.  Seven  weeks  before  admission, 
while  polishing  a  floor  on  his  knees  and  with  his 
head  low,  his  nose  began  to  bleed.  This  continued 
for  nine  hours,  and  it  had  frequently  recurred  for 
short  periods.  Of  late,  also,  there  had  been  a  little 
shortness  of  breath.  On  admission,  he  was  found  to 
be  very  thin  and  extremely  pallid.  Pulsation  was 
visible  in  all  the  superficial  arteries.  Pulse,  100; 
sudden,  forcible,  collapsing.  The  area  of  cardiac  dull- 
ness was  much  increased,  and  the  impulse  diffused 
and  visible.  Four  murmurs  could  be  heard :  at  the 
base  a  systolic  and  a  loud  diastolic,  at  the   apex  a 

132 


CASES  IN  DETAIL  133 

presystolic  and  a  systolic.  The  liver  was  enlarged; 
the  urine  albuminous,  with  hyaline  casts  and  a  trace 
of  blood.  The  lungs  were  normal.  Temperature 
ranged  between  98.4''  and  99.8°. 

A  few  days  later  it  was  noticed  that  the  presystolic 
murmur  occupied  a  considerable  part  of  the  diastole, 
and  became  of  a  higher  pitch  at  the  end,  running  up 
into  the  systole.  But  on  9th  May  it  was  recorded 
that  "the  presystolic  murmur  observed  for  several 
days  cannot  be  distinctly  made  *6ut  to-day,"  though 
the  aortic  murmurs  were  loud.  On  the  same  date 
the  spleen  was  felt,  just  below  the  margin  of  the  ribs, 
and  some  fine  crackling  sounds  could  be  heard  in  the 
left  lower  axillary  region  :  the  patient  had  complained 
of  a  sudden  sharp  pain  in  this  region  the  day 
previously,  and  the  temperature  had  risen  to  101°. 
The  urine  Was  pale,  clear,  acid,  of  specific  gravity 
1012  ;  it  contained  albumen,  granular  and  blood  casts, 
and  blood-corpuscles,  though  not  in  sufficient  amount 
to  colour  it.  Next  day  (loth  May)  a  very  large  increase 
of  the  splenic  dullness  was  noted,  and  the  spleen  was 
felt  below  the  ribs,  its  lower  limit  being  one  inch 
above  the  level  of  the  umbilicus.  The  presystolic 
murmur  was  still  absent,  and  the  systolic  mitral  had 
developed  a  distinctly  musical  character  which  it  had 
not  possessed  before.  But  on  the  nth  the  presystolic 
was  again  detected,  and  on  the  19th  it  was  distinct, 
while  the  systolic  had  vanished,  the  first  sound  at  the 
apex  being  now  short  and  sharp.  Another  attack  of 
pain  in  the  left  side  had  occurred,  and  the  spleen  was 
larger. 

I  first  saw  the  patient  on  23rd  May,  on  succeeding 
Sir  E.  Sieveking  in  charge  of  in-patients.  There 
were  then  a  double  aortic  and  a  presystolic  mitral 
murmur,  but  the  systolic  mitral  murmur  could  not 
be  heard.  The  first  sound  was  short  at  the  apex, 
the  second  absent.     The  treatment  consisted  of  15- 


134  PRESYSTOLIC  APEX-MURMUR 

grain  doses  of  sulphocarbolate  of  sodium  every  four 
hours,  and  this  was  continued.  A  few  purpuric  spots 
developed  on  the  patient's  legs,  but  on  the  whole  his 
condition  gradually  improved  ;  the  epistaxis  ceased 
to  recur,  his  strength  increased,  and  at  the  end  of 
June  he  was  so  much  better  that  he  was  allowed  to 
be  up.  The  improvement  continued,  and  on  loth 
July  he  was  permitted  to  go  home. 

On  27th  July  he  was  readmitted,  on  account  of 
recurrence  of  epistaxis.  On  ist  August  I  made  the 
following  note :  "  Heart's  impulse  wavy,  and  diffused 
over  a  wide  area ;  most  marked  about  three  finger- 
breadths  below  and  two  to  the  outer  side  of  the  nipple. 
No  thrill,  but  over  the  apex-beat  there  is  a  well- 
marked  presystolic  murmur  continued  to  the  systole ; 
this  cannot  be  heard  to  the  right  of  the  nipple-line. 
At  one  point,  just  outside  the  impulse,  a  presystolic 
murmur  and  first  and  second  sounds  can  be  heard. 
Further  to  the  left  no  murmur  is  audible,  but  a  short, 
forcible  first  sound  followed  by  a  second.  The  aortic 
diastolic  murmur  is  loud  at  the  base,  and  is  conducted 
downward  more  toward  the  apex  than  down  the 
sternum  ;  it  is  audible  nearly  to  the  nipple-line,  but 
is  not  audible  at  the  xiphoid.  Pulse  highly  character- 
istic of  aortic  regurgitation."  On  the  evening  of  this 
day  he  had  another  sudden  attack  of  pain  in  the 
splenic  region.  A  week  later  I  noted  that  "  the  aortic 
diastolic  murmur  can  be  traced  obliquely  downward 
to  the  fifth  rib,  about  one  fingerbreadth  to  the 
inner  side  of  the  nipple-line,  and  immediately  below 
this  the  presystolic  murmur  commences." 

He  was  again  treated  with  sulphocarbolate  of 
sodium,  and  with  dialysed  iron,  but  his  strength 
gradually  failed.  Recurrence  of  epistaxis,  diarrhoea, 
and  increasing  feebleness  brought  the  end  on  4th 
September, 

The  post-mortem  examination  was  made  the  next 


DUE  TO  AORTIC  REGURGITATION         135 

day  by  my  colleague,  Dr  Maguire.  The  pericardium 
was  adherent  to  the  heart  throughout  by  fibrous 
bands,  and  some  similar  bands  passed  from  the  front 
of  the  pericardium  to  the  under  surface  of  the  ribs. 
The  heart  was  much  enlarged,  especially  the  left 
ventricle.  The  mitral  oi'ifice  admitted  tJiree  fingers^ 
the  tricuspid  four.  All  the  cavities  contained  post- 
mortem clot,  and  adhesive  ante-mortem  clot  was  also 
found  in  the  right  auricle  and  in  both  ventricles. 
The  pulmonary  and  tricuspid  valves  were  normal. 
On  the  right  posterior  cusp  of  the  aortic  valve  and 
immediately  below  it  were  fresh  vegetations  with 
ulcerations.  All  the  cusps  were  thickened  from  old 
endocarditis.  Below  the  anterior  cusp  was  a  large 
vegetation  of  fibrin  adherent  to  a  roughened  inflamed 
surface  of  endocardium  apparently  not  ulcerated. 

The  mitral  valve-flaps  were  similarly  thickened, 
and  on  the  auricular  surface  of  the  anterior  flap  at 
its  middle  portion,  and  also  on  the  chordae  tendineae, 
were  patches  of  recent  endocarditis  without  ulceration. 
The  lungs  were  congested  and  oedematous.  There 
were  some  old  fibrous  adhesions  at  the  base  of  the 
left  pleura.  Liver  large  and  firm.  Spleen  much 
enlarged,  weighing  fifteen  ounces,  its  surface  mottled 
with  small  white  spots.  It  contained  a  yellow  infarct 
of  the  size  of  a  walnut.  Both  kidneys  also  contained 
small  infarcts. 

As  this  patient  died  during  my  autumn  holiday,  I 
was  not  present  at  the  autopsy.  Nine  months  later, 
however,  I  discovered  that  the  heart  had  been  pre- 
served for  the  Museum,  and  had  an  opportunity  of 
examining  it  with  Dr  Maguire.  The  weight  of  the 
heart  was  now  fifteen  and  a  half  ounces.  We  found 
that  at  this  time  the  mitral  orifice  would  not  admit 


136  PRESYSTOLIC  APEX-MURMUR 

more  than  two  fingers,  and  that  with  some  little 
difficulty.  Dr  Maguire,  however,  felt  confident  that 
the  post-mortem  record  was  correct,  and  that  at  the 
time  of  the  autopsy  the  orifice  admitted  three  fingers. 
Thinking  that  possibly  the  action  of  the  spirit  in 
which  the  specimen  had  been  preserved  for  nine 
months  might  have  caused  some  contraction,  we 
examined  another  heart  in  the  Museum,  taken  from 
a  case  of  aortic  aneurism  with  normal  mitral  flaps. 
In  this  case,  the  left  ventricle  being  large,  it  is  prob- 
able that  the  mitral  orifice  may  have  been  somewhat 
dilated  during  life,  yet  we  found  that  now  after  having 
been  preserved  in  spirit,  the  orifice  would  not  admit 
more  than  two  fingers  comfortably.  It  therefore 
seemed  likely  that  in  the  other  case  there  had  been 
little  or  no  stenosis,  and  that  the  post-mortem  record 
was  correct. 

Case  II. — James  B.,  aged  30  years,  admitted  into 
St  Mary's  Hospital,  under  my  care,  loth  October 
1889,  suffering  from  dyspnoea  and  ascites.  He  was 
found  to  have  a  very  large  heart ;  the  impulse  could 
be  felt  four  fingerbreadths  below  and  five  finger- 
breadths  to  the  outer  side  of  the  nipple  in  the  anterior 
axillary  line. 

The  cardiac  dullness  was  extensive  also  in  the 
upward  direction,  and  involved  even  the  manubrium 
and  the  first  and  second  intercostal  spaces  at  the  left 
margin  of  the  sternum.  A  loud,  rough,  systolic 
murmur  was  heard  over  the  whole  of  this  basic  area, 
and  in  the  second  right  interspace  close  to  the  sternum 
a  very  local,  short,  diastolic   murmur  was  detected. 


DUE  TO  AORTIC  REGURGITATION         137 

In  addition,  the  pulse-wave  in  the  left  radial  artery- 
was  always  smaller  than  that  in  the  right  These 
symptoms  had  led  to  a  diagnosis  of  aortic  aneurism 
before  his  admission.  Not  the  slightest  pulsation, 
however,  could  be  seen  in  the  upper  part  of  the 
thorax,  and  I  was  decidedly  of  opinion  that  the  case 
was  essentially  one  of  aortic  regurgitation.  At  the 
apex  a  double  murmur  was  audible,  which  varied  in 
character  on  different  occasions.  Sometimes  it  was 
systolic  and  diastolic,  at  other  timss  it  was  distinctly 
presystolic  and  systolic.  I  noted,  however,  that  the 
presystolic  murmur,  when  it  occurred,  was  of  a  blowing, 
not  rumbling,  character,  and  was  short.  At  the 
xiphoid  a  tricuspid  systolic  murmur  could  be  heard. 
The  patient  suffered  from  ascites  and  flatulence.  The 
liver  -  was  enlarged,  its  edge  reaching  four  finger- 
breadths  below  the  costal  margin ;  it  was  firm  and 
tender.  Not  much  oedema  of  the  legs.  Urine  of  sp. 
gr.  1024,  albuminous.  The  patient  stated  that  he 
had  never  had  rheumatic  fever,  though  he  had  been 
troubled  occasionally  with  "  rheumatic  pains."  On 
the  26th  of  October  he  suddenly  fell  back  dead. 

At  the  autopsy  it  was  found  that  the  heart  was 
very  large,  weighing  35  oz.  with  the  contained  clots, 
2/1^  oz.  without  them.  The  aortic  valves  were  fused 
into  a  calcareous,  rigid  mass,  occupying  fully  three- 
fourths  of  the  orifice.  An  aperture  of  about  the 
diameter  of  a  cedar  pencil  remained  ;  it  was  situated 
in  the  left  half  of  the  normal  position  of  the  orifice, 
so  that  the  stream  of  blood  regurgitating  through  it 
must  have  impinged  on  the  anterior  flap  of  the  mitral. 
The  mitral  orifice  admitted  three  fingers  readily^  the 
flaps  were  healthy  except  for  a  very  little  atheroma 
of  the  base  of  the  anterior  one;  they  were  not 
shrunken  or  deformed.  The  tricuspid  and  pulmonary 
valves  were  normal.  Liver,  nutmeg  and  fatty. 
Kidneys  of  normal  size,  capsules   slightly  adherent. 


138  PRESYSTOLIC  APEX-MURMUR 

About  two  inches  of  each  radial  artery  was  excised  ; 
they  were  equal  in  size,  but  while  the  vessel  from  the 
right  side  was  normally  round,  that  from  the  left  side 
was  distinctly  flattened,  as  if  it  had  long  been  only 
partially  filled.  It  appeared  that  this  must  have  been 
due  to  the  aortic  stenosis,  the  onward  current  of  blood 
being  directed  mainly  toward  the  innominate  artery. 

Case  III. — William  M.,  aged  31  years,  admitted 
into  St  Mary's  Hospital  22nd  (October  1889.  He 
had  never  had  rheumatism.  Twelve  years  ago  he 
had  a  chancre  and  buboes.  Three  months  ago  he 
began  to  have  pains  in  his  stomach,  worse  after  meals, 
and  shortness  of  breath  after  exertion. 

On  admission  there  was  orthopnoea,  throbbing  of 
carotids,  yellowish  complexion,  much  dropsy  of  legs 
and  scrotum,  and  much  albumen  in  the  urine.  Respir- 
ations, 36 ;  lungs,  normal,  except  for  some  moist 
sounds  at  the  bases.  The  cardiac  dullness  was  very 
extensive,  from  the  right  margin  of  the  sternum  to 
the  left  anterior  axillary  fold.  The  cardiac  impulse 
was  diffused,  being  seen  and  felt  in  the  fifth  and 
sixth  interspaces,  from  one  inch  on  the  inner  side  of 
the  nipple-line  to  two  inches  on  its  outer  side.  At 
the  base  a  double  murmur  was  heard,  the  systolic 
being  conducted  upward,  the  diastolic  downward 
along  the  left  side  of  the  sternum,  and  loudest  in  the 
third  space.  At  the  point  of  maximum  impulse,  in 
the  sixth  space,  two  inches  outside  the  nipple-line, 
systolic  and  diastolic  murmurs  could  be  heard,  but  to 
the  inner  side  of  the  nipple-line,  less  than  an  inch 
below  the  nipple,  and  the  same  distance  to  the  right 
of  it,  a  disti7ict  presystolic  viurnmr  was  heard.  It  was 
decidedly  rumbling  in  character,  but  it  did  not  increase 
in  intensity  toward  its  close,  and  did  not  run  into  a 
"  snap!'  This  presystolic  murmur  was  not  invariably 
present,  but  it  was  heard  three  times  at  least  during 


DUE  TO  AORTIC  REGURGITATION         139 

the  twelve  days  during  which  he  was  under  observa- 
tion. 

Pulse,  1 08  ;  somewhat  collapsing  in  character,  not 
full  between  the  beats,  and  quite  small  in  size.  From 
this  smallness  of  the  pulse  and  the  presystolic  murmur, 
I  thought  it  probable  that  there  really  was  mitral 
stenosis  in  this  case  as  well  as  aortic  incompetence, 
but  the  autopsy  showed  that  the  smallness  must  have 
been  due  to  mitral  regurgitation.  Four  days  before 
death  it  was  reported  that  his  urine  was  of  specific 
gravity  1015,  free  from  albumen.  He  died  3rd 
November. 

Post-mortem. — Heart  very  large,  weight  35  oz. ;  all 
the  cavities  dilated.  Muscular  tissue  of  heart  normal 
in  colour,  thickness,  and  consistency.  The  mitral 
orifice  admitted  five  fingers  ;  the  mitral  flaps  normal; 
chordae  tendineae  normal.  Aortic  valves  incompetent ; 
cusps  slightly  thickened,  but  not  much  deformed. 
Aorta  highly  atheromatous,  in  patches  just  above  the 
aortic  valves.  Tricuspid  normal.  Pulmonary  valve 
had  only  two  cusps,  but  was  otherwise  normal.  The 
lungs  contained  large  haemorrhagic  infarcts  in  the 
lower  lobe  of  each  and  the  right  middle  lobe.  Kidneys 
enlarged,  each  weighed  10  oz. ;  capsule  normal,  surface 
smooth  and  pale.  Liver  enlarged  (5  lbs.  i  oz.),  section 
fatty  and  nutmeg.     Spleen,  7  oz.,  normal. 

Case  IV. — William  B.,  aged  45  years,  admitted 
into  St  Mary's  Hospital  13th  May  1890.  He  had 
never  had  rheumatic  fever.  Stated  that  he  had  not 
taken  much  alcohol,  and  that  he  had  never  had 
syphilis.  His  first  symptom  was  swelling  of  the  feet 
five  weeks  before  admission.  Dyspnoea  had  been 
present  only  for  one  week.  On  admission  there  was 
some  orthopncea.  Pulse,  100;  collapsing, yet  the  vessel 
remained  distended  between  the  beats.  The  cardiac 
dullness  extended  to  the  nipple-line,  impulse  feeble. 


140  PRESYSTOLIC  APEX-MURMUR 

At  the  base  a  double  murmur — systolic  loud,  diastolic 
not  loud,  and  heard  best  in  the  fourth  left  interspace. 
The  second  pulmonary  sound  was  accentuated.  A  t  the 
spot  where  the  apex-beat  should  normally  be  found  there 
was  a  presystolic  murmur,  not  long,  but  of  a  definitely 
"  cantering"  character.  This  murmur  was  very  local ; 
a  little  way  to  the  left  of  this  site  it  vanished,  and  a 
systolic  blowing  murmur  became  audible.  Liver 
much  enlarged  ;  no  ascites.  Catarrhal  sounds  gener- 
ally over  the  lungs.  The  patient  died  six  days  after 
his  admission. 

Post-mortem. — Heart  weighed  19  oz.  Left  side 
empty.  Right  auricle  not  distended.  Aortic  valves 
quite  incompetent  and  much  diseased  ;  the  anterior 
and  right  posterior  cusps  were  united  along  their 
margin,  so  that  the  regurgitant  stream  must  have 
been  directed  toward  the  mitral  valve.  All  the  cusps 
were  covered  with  warty  vegetations,  with  some 
ulceration.  The  mitral  orifice  admitted  four  fingers  ; 
the  tricuspid  five  fingers.  The  anterior  flap  of  the 
mitral  and  its  chordae  tendineae  were  thickened,  but 
not  shrunken ;  the  posterior  flap  was  very  slightly 
thickened.  The  pulmonary  and  tricuspid  valves 
were  normal.  The  spleen  and  kidney  contained 
infarcts. 

It  was  stated  some  years  ago  by  the  late  Dr  Austin 
Flint,  of  New  York,  that  in  certain  cases  of  aortic 
regurgitation  a  presystolic  apex-murmur  might  exist 
without  any  stenosis  of  the  mitral  orifice.  This  state- 
ment has  not  met  with  much  acceptance,  even  in 
the  latest  edition  (1890)  of  the  text-books  on 
medicine.  In  the  interesting  discussion  on  the 
"presystolic  murmur,  falsely  so  called,"  initiated 
by  Dr   Dickinson  in  the  columns  of  the  Lancet  in 


CASES  RELATED  BY  OTHERS  141 

October     1887,    and    carried    on    by    Dr    Bristowe, 
Professor    Gairdner,  and    many   other  distinguished 
physicians,  it  was  assumed  on  both  sides  that  what- 
ever might   be  the  true   rhythm  of  th-e   murmur  in 
question,  it  is  at  all  events  pathognomonic  of  mitral 
stenosis.     Even  Dr  Gairdner  only  inserted  in  a  foot- 
note the  following  rather  sceptical  reference  to  Dr 
Flint's  claim :    "  I   will   observe   a  sjmilar  reserve   as 
regards  Dr  Austin  Flint's  curious  but  exceptional  ex- 
perience of  a  murmur,  apparently  of  mitral  stenosis, 
going  along  with  free  aortic  regurgitation,  and  with 
an   uninjured   mitral  valve  and  orifice."     Since  that 
time,  however,  Dr    Gairdner   has  published,  in  the 
American  Joufnal  of  the  Medical  Sciences  for  August 
1889,  a   case   which   supports    Dr    Flint's   view,   for 
the  autopsy  showed  that    aortic    incompetence   was 
present,  and  Dr  Gairdner's  statement  implies  that  the 
mitral  was  normal,  though  he  does  not  expressly  say  so. 
In    the    Medical    CJironicle    for    June     1890,    my 
colleague,  Dr  Maguire,  has  given  a  summary  of  the 
cases  supported  by  post-mortem   proof  of  non-con- 
tracted  mitral  which  have  thus  far  been  published. 
They  are  nine  in   number — three  by  Flint,  two  by 
Guiteras,  one  by  Steell,  one  by  Gairdner,  and  two  by 
Osier.     He  adds  a  detailed  account  of  two  cases,  one 
of  his  own  and  one  which  was  under  my  own  care, 
and  in  which  he  made  the  post-mortem  examination. 
In  the  former,  a  typical  case  of  aortic  regurgitation, 
"  about  one  incJi  ifiside  and  a  little  above  the  apex-beat^ 


142  PRESYSTOLIC  APEX-MURMUR 

there  was  heard  a  presystolic  murmur^  not  roughs  but 
rather  blowing,  distinctly  separated  from  the  second 
sound,  and  terminated  by  a  normal  first  sound.  The 
murmur  was  heard  over  only  a  limited  area.  .  .  .  The 
presystolic  murmur  remained  for  a  week,  and  was 
distinctly  heard  both  by  my  colleague,  Dr  Cheadle,  and 
myself.  The  autopsy  showed  that  the  heart  was 
greatly  enlarged,  weighing  22  ounces.  All  its  cavities 
were  dilated.  The  aortic  valve  was  markedly  incom- 
petent ;  its  cusps  much  thickened  and  shrunken.  The 
thoracic  aorta  was  extremely  atheromatous  and 
thickened.  TJie  mitral  orifice  admitted  easily  three 
fingers.  The  anterior  flap  was  slightly  thickened, 
and  while  its  auricular  surface  was  smooth,  its  ventri- 
cular surface  was  very  slightly  roughened.  The 
posterior  flap  was  normal,  and  the  chordae  tendineae 
were  neither  thickened  nor  shortened." 

The  second  case  was  one  of  great  pathological 
interest,  and  I  therefore  quote  Dr  Maguire's  account 
of  it  in  full : 


H.  S.,  aged  55  years,  was  admitted  into  St 
Mary's  Hospital  on  21st  October  1887,  under  the 
care  of  Dr  Lees,  who  has  kindly  given  me  permission 
to  make  use  of  the  case.  He  had  never  had  rheuma- 
tism, had  lived  in  London  all  his  life,  and  had  drunk 
spirits  and  beer  to  excess.  He  had  suffered  for  four 
or  five  months  from  dyspepsia  and  pains  in  various 
parts,  and  these  had  increased  up  to  the  time  of 
admission.  Suppressing  the  immaterial  details,  I 
may  relate  that  on  examining  the  heart  there  was 


CASE  OF  CORONARY  ANEURISM  143 

seen  a  very  diffused  apex-beat,  but  the  true  apex 
seemed  to  be  in  the  fifth  interspace  slightly  outside 
the  nipple-line.  There  were  evident  signs  of  cardiac 
dilatation  affecting  both  the  right  and  the  left  sides. 
At  the  aortic  cartilage  the  first  sound  was  weak,  the 
second  accentuated.  At  the  fourth  left  interspace, 
near  the  sternum,  was  heard  a  diastolic  murmur 
carried  downward  to  the  ensiform  cartilage.  Just 
below  the  nipple  a  short  presystolic  murviur  was  heard, 
blowing  in  character,  and  heard  not  quite  so  distinctly 
at  the  cardiac  apex.  The  pulse  was  collapsing  and 
short,  and  capillary  pulsation  was  very  evident.  On 
26th  October  it  was  noted  that  the  presystolic  murmur 
was  much  rougher  in  character ;  that  it  led  up  to  the 
first  sound,  and  that  it  was  now  heard  two  finger- 
breadths  outside  the  nipple.  On  29th  October  no 
presystolic  murmur  was  heard.  In  the  nipple-line 
there  was  found  a  sharp  first  sound,  a  short  systolic 
murmur,  and  a  short  diastolic  murmur.  On  31st 
October,  in  the  fourth  left  interspace  near  the  sternum, 
a  short  systolic  and  a  rather  long  diastolic  murmur 
were  heard,  but  no  presystolic  murmur  was  found 
anywhere.  At  the  cardiac  apex  there  was  a  short 
systolic  murmur  carried  for  a  little  distance  into  the 
axilla.  On  7th  November  the  diastolic  murmur  was 
conducted  down  to  the  apex.  Thus,  while  the  main 
signs  of  the  case  were  those  of  aortic  regurgitation,  a 
distinct  presystolic  murniur  was  heard  for  a  short'  time 
near  tJie  cardiac  apex.  I  made  an  autopsy  upon  this 
case  and  found  the  heart  greatly  enlarged,  weighing 
2 5 -J  ozs.,  the  enlargement  being  the  more  marked  in 
the  left  ventricle.  The  aortic  valves  were  incompetent 
and  showed  advanced  atheroma,  which  had  produced 
great  shrinking  of  the  segments.  The  sinuses  of 
Valsalva  above  the  right  and  anterior  aortic  segments 
were  much  pouched,  and  the  artery  around  them  was 
in  an  advanced  state  of  atheroma.     In  the  wall  of  the 


144  PRESYSTOLIC  APEX-MURMUR 

posterior  sinus  of  Valsalva  an  opening  which  admitted 
easily  the  little  finger  represented  the  orifice  of  the 
left  coronary  artery.  The  artery  beyond  this  was 
transformed  into  a  calcareous  tube,  somewhat  larger 
in  diameter  than  the  opening  mentioned  by  which  it 
communicated  with  the  aorta,  and  lay  in  the  auriculo- 
ventricular  groove  until  the  anterior  sulcus  between 
the  two  ventricles  was  reached.  Here  the  aneurism, 
for  its  nature  was  evident,  ended  by  dividing  into  the 
ordinary  branches  of  the  coronary  artery,  which 
appeared  to  be  of  normal  size  and  structure.  The 
aneurism  bulged,  on  its  inner  aspect,  into  the  cavity 
of  the  left  auricle  above  the  anterior  cusp  of  the  mitral 
valve.  The  bulging  at  this  spot  somewhat  diminished 
the  calibre  of  the  auricle,  but  it  seemed  to  be  quite 
clear  of  the  cusps  of  the  mitral  valve  and  of  the 
auriculo-ventricular  orifice.  The  aneurism  was  empty. 
The  mitral  orifice  admitted  three  fingers  easily.  On 
the  anterior  cusp  of  the  mitral  valve  there  were  seen 
a  few  scattered  patches  of  atheroma,  but  otherwise 
no  abnormal  appearance  was  noticed,  and  the  chordae 
tendineae  were  healthy.  All  the  cavities  of  the  heart 
were  dilated.  Here,  then,  we  had,  in  addition  to  the 
lesion  of  the  aortic  valve  which  caused  its  incompe- 
tence, an  aneurism  of  the  left  coronary  artery  which 
caused  a  projection  into  the  left  auricle.  Yet  I  think, 
on  careful  examination  of  the  specimen,  that  this 
latter  lesion  could  not  in  any  way  interfere  with  the 
flow  of  blood  through  the  mitral  orifice.  Moreover, 
the  extent  of  the  projection  could  be  well  judged 
after  death,  for  the  extreme  calcification  of  the 
aneurism  would  entirely  prevent  any  further  expansion 
of  the  vessel  during  life.  The  case  seems  to  be  truly 
a  companion  to  that  previously  described,  and  thus 
we  have  two  examples  of  presystolic  murmur  without 
mitral  stenosis,  and  apparently  the  result  of  aortic 
regurgitation. 


CASES  WITHOUT  AUTOPSY  145 

I  entirely  endorse  Dr  Maguire's  description  of  this 
case,  and  his  remarks  upon  it. 

Adding  these  two  cases  to  the  four  which  I  have 
above  narrated,  and  to  the  nine  mentioned  in  Dr 
Maguire's  paper,  we  have  fifteen  cases  by  various 
observers  in  which  a  murmur  of  presystoHc  rhythm 
has  been  heard  in  cases  of  aortic  regurgitation  in 
which  it  has  subsequently  been  pfoved  by  autopsy 
that  no  stenosis  of  the  mitral  existed.  Cases  without 
autopsy  are  of  course  worthless  as  proof,  but  they 
may  be  referred  to  as  illustrations.  Dr  Maguire 
quotes  one  of  his  own  and  another  of  Dr  Bramwell's, 
in  which  a  presystolic  murmur  existed  in  a  case  of 
aortic  regurgitation  believed  to  be  free  from  mitral 
stenosis.  I  have  such  a  case  under  my  care  at 
present.  It  is  a  case  of  severe  aortic  regurgitation  in 
a  man  of  twenty-six,  in  which  there  is  a  typical 
double  murmur  at  the  base  and  also  a  rather  loud 
systolic  followed  by  a  short  diastolic  at  the  apex.  He 
has  frequent  anginal  attacks.  On  several  occasions  I 
have  heard  a  faint  presystolic  murmur  to  the  inner 
side  of  the  apex-beat,  and  a  few  days  ago  I  noticed 
that  it  was  distinctly  present  after  the  slight  exertion 
of  taking  off  his  shirt,  but  that  in  a  minute  or  two 
the  rhythm  changed  into  systolic  and  diastolic.  On 
making  him  sit  up  in  bed  the  presystolic  murmur 
reappeared,  to  vanish  again  after  a  minute  or  two.  I 
think  it  is  reasonably  certain  that  this  patient  has 
no  mitral  stenosis. 

K 


146  PRESYSTOLIC  APEX-MURMUR 

I  have  said  above,  "  a  murmur  of  presystolic 
rhythm,"  for  it  must  be  confessed  that  it  does  not 
usually  simulate  very  closely  the  rumbling,  cantering 
sound  of  the  murmur  of  mitral  contraction.  It  is 
usually  short  and  rather  blowing  in  character.  But 
it  may  partake  somewhat  of  the  well-known  quality, 
and  in  Case  III.  this  circumstance,  conjoined  with 
the  smallness  of  the  pulse,  led  me  to  diagnose  a 
stenosis  which  the  post-mortem  examination  proved 
to  be  absent.  In  Case  I.  the  presystolic  murmur 
was  long  and  quite  typical,  and  was  even  reported  to 
have  been  accompanied  by  a  thrill  (this,  however,  was 
not  present  while  the  case  was  under  my  own 
observation).  It  is  unfortunate  that  in  this  case  the 
condition  of  the  heart  nine  months  afterwards  threw 
some  doubt  on  the  accuracy  of  the  record  of  the  post- 
mortem examination.  But  if  any  stenosis  existed,  it 
must  have  been  very  slight,  and  the  aortic  regurgita- 
tion gave  rise  to  the  most  extreme  and  characteristic 
symptoms.  In  the  light  of  the  other  cases,  I  have  no 
doubt  that  the  presystolic  murmur  was  in  great  part, 
if  not  entirely,  due  to  the  aortic  regurgitation.  It  is 
worthy  of  note  that  in  this  case  there  was  a  large 
vegetation  below  the  anterior  cusp  of  the  aortic  valve, 
and  vegetations  also  on  and  below  the  right  posterior 
cusp ;  hence  the  regurgitant  stream  was  probably 
mainly  directed  toward  the  left,  and  it  would  therefore 
strike  the  anterior  mitral  flap.  Similarly,  in  Case  IV. 
the  anterior  and  right  posterior  cusps  of  the  aortic 


HOW  PRODUCED  147 

valve  were  actually  united  along  their  margin,  leaving 
the  left  half  of  the  orifice  alone  patent ;  and  in  Case 
II.  the  pathological  process  had  gone  on  to  com- 
pletely calcified  union  of  the  cusps,  leaving  again  as 
patent  opening  only  the  left  portion  of  the  normal 
orifice.  Hence,  in  all  these  three  cases  the  regurgitant 
stream  must  have  impinged  on  the  anterior  mitral 
flap,  and  there  is  no  difficulty  in  seeing  how  this  flap 
was  in  consequence  thrown  into  vibrations  when  it 
was  carried  outward  by  the  incoming  current  through 
the  mitral  orifice  at  the  end  of  the  diastole.  For,  "  in 
full  diastole  "  (to  quote  Dr  M'Alister's  account  of  the 
observations  of  Ludwig  and  Hesse,  British  Medical 
Journal,  1882,  vol.  ii.  p.  825),  "the  flap  and  its  cords 
are  stretched  aslant  across  the  cavity.  .  .  .  The  flap 
does  not  hang  loosely  down  ;  it  is  stretched  taut  from 
basal  ring  to  muscle-tip."  Hence,  under  the  influence 
of  two  independent  blood-currents  impinging  on  its 
opposite  sides,  vibrations  are  easily  produced  and  give 
rise  to  a  murmur  during  the  ventricular  diastole, 
more  especially  during  its  closing  period,  which  corre- 
sponds with  the  systole  of  the  auricle. 


THE  ICEBAG  AS   A  THERAPEUTIC 
AGENT. 

( Clinical  Journal ,  1892.) 

The  value  of  the  icebag  in  therapeutics  is  still  very 
inadequately  recognised.  Tradition  sanctions  its 
employment  for  the  arrest  of  haemorrhage  in  haemop- 
tysis and  in  typhoid  fever,  though  its  utility  in  these 
conditions  is  open  to  question.  But  in  visceral 
inflammations,  with  the  single  exception  of  meningitis, 
it  has  been  avoided  and  even  imagined  to  be  danger- 
ous. Moist  warmth  has  been  relied  upon  to  relieve 
pain  and  to  dilate  the  superficial  blood-vessels,  so  that 
the  application  of  poultices  has  long  been  the  routine 
treatment  of  visceral  inflammations,  and  a  diagnosis 
of  pneumonia,  pericarditis,  pleurisy,  or  peritonitis 
appears  to  the  majority  of  practitioners  an  irresistible 
call  for  poultices.  But  the  reign  of  the  poultice  has 
nearly  ended.  In  surgery  it  has  been  almost  banished 
by  the  antiseptic,  and  still  more  by  the  aseptic  measures 
which  have,  during  the  last  fifteen  years,  completely 
transformed  surgical  treatment.     In  medicine  it  still 

148 


SUPERIOR  TO  POULTICES  149 

exists  in  some  quarters  as  a  survival — not  of  the 
fittest,  for  in  medical  cases  in  which  moist  warmth  is 
desirable,  hot  moist  flannels,  with  or  without  the 
addition  of  turpentine,  are  usually  to  be  preferred. 
But  it  will  soon,  I  believe,  be  generally  recognised 
that  many  visceral  inflammations  ought  to  be  treated, 
not  with  warmth,  but  with  the  local  application  of 
cold,  precautions  being  of  course  ta'ken  to  prevent  any 
undue  chilling  of  the  body  generally. 

My  first  experience  in  the  use  of  the  icebag  in 
pneumonia  was  in  January  1885,*  and  the  remarkable 
benefit  which  followed,  when  it  replaced  the  poultices 
employed  during  the  first  two  days  of  treatment, 
impressed  me  greatly.  And  in  this  first  case  I  noted 
a  fact  which  I  have  often  observed  subsequently,  and 
which  is  of  the  greatest  importance  in  an  estimate  of 
the  value  of  this  treatment — the  fact  that  where  the 
icebag  had  been  applied  there  was  produced  a  rapid 
improvement  in  the  physical  signs,  although  at  the 
same  time  the  disease  was  still  present,  and  some- 
times even  extending,  in  other  parts  of  the  lung. 

In  the  Lancet  for  2nd  November  1889,  I  published 
an  account  of  eighteen  cases  of  Lobar  Pneumonia  and 
Bronchopneumonia  treated  with  the  icebag,  all  of 
which  recovered.  In  that  paper  I  drew  attention  to 
the  fact  that  the  improvement  caused  by  the  icebag 
was  not  simply  a  reduction  of  temperature  (though 

*  "Two  Cases  of  Bronchopneumonia  treated  with  Bleeding 
and  Ice." — British  Medical  Journal^  nth  July  1885. 


150    THE  ICEBAG  AS  A  THERAPEUTIC  AGENT 

that  often  occurred  to  the  extent  of  3°  or  4°),  but  was 
also  a  remarkable  diminution  of  the  physical  signs 
over  the  diseased  area  and  an  amelioration  of 
symptoms.  I  will  here  quote  two  of  these  cases  to 
illustrate  this  statement : — 

Case  XV. — Mary  A ,  aged  20,  admitted  into 

St  Mary's  Hospital  i  ith  May  1889,  on  the  fourth  day 
of  a  pneumonia  commencing  at  the  right  apex.  She 
had  a  most  unfavourable  family  history.  She  stated 
that  her  father  suffered  from  asthma,  that  her 
mother  had  died  of  "  galloping  consumption,"  that  she 
had  lost  ten  brothers  and  sisters,  and  that,  of  the 
three  who  survived,  two  suffered  from  consumption. 
She  had  herself  spat  blood  at  times  during  the  last 
two  years.  She  had  also  suffered  from  "fits"  for  four 
years,  and  the  onset  of  her  pneumonia  was  marked 
by  a  fit  instead  of  a  rigor.  I  saw  her  first  on  the  fifth 
day  of  her  illness,  and  found  evidence  of  pneumonia 
at  the  right  apex,  with  temperature  104°,  pulse  128, 
and  respirations  48. 

An  icebag  was  applied  over  the  affected  apex  at 
noon.  At  6  o'clock  the  next  morning  the  tempera- 
ture had  fallen  4°,  but  in  the  course  of  the  day  it 
rose  again  to  102°.  The  pulse  remained  at  130,  but 
the  number  of  respirations  had  risen  from  48  to  74, 
and  some  cyanosis  had  appeared.  The  upper  part  of 
the  right  lung,  both  in  front  and  behind,  was  now  dull, 
as  far  down  as  the  angle  of  the  scapula.  On  14th 
May,  the  seventh  day  of  her  illness,  the  temperature 
was  still  only  at  102.5°,  though  the  pulse  was  nearly 
130,  and  the  number  of  respirations  had  risen  to  100. 
The  right  lung  seemed  now  to  be  involved  in  its  entire 
extent.  Both  cheeks  were  markedly  cyanosed,  and 
the  sputum,  which  was  scanty,  very  viscid,  and  a  little 
aerated,  was  of  exceedingly  dark  colour,  almost  black, 


USEFULNESS  IN  PNEUMONIA  151 

the  "prune-juice"  expectoration  admitted  to  be  of 
evil  omen.  A  much  larger  icebag  was  now  obtained, 
capable  of  surrounding  the  whole  right  chest,  and  this 
was  applied  at  5  P.M.  Four  ozs.  of  brandy  daily  were 
ordered  for  her,  and  an  ether  and  ammonia  mixture 
every  four  hours.  On  the  next  day,  the  eighth,  the 
temperature  ranged  about  a  degree  lower  (101.5''),  the 
pulse  remaining  at  120,  and  the  respirations  still  from 
88  to  100.  But  it  was  observed  that  the  sputum  was 
distinctly  less  dark,  and,  at  the  same  time,  less  viscid 
and  more  abundant.  On  the  ninth  day  the  tempera- 
ture, pulse,  and  respiration  remained  about  the  same, 
but  an  extraordinary  improvement  had  occurred  in 
the  physical  signs.  There  was  now  very  fair  reson- 
ance over  both  back  and  front  of  the  right  lung  down 
to  the  angle  of  the  scapula,  with  large  moist  rales  in 
front,  and  smaller  rales  with  more  natural  breathing 
behind.  Below  the  angle  of  the  scapula  there  was 
dullness,  with  fine  moist  rales,  both  inspiratory  and 
expiratory.  There  was  still  further  improvement  in 
the  appearance  of  the  sputum. 

On  the  tenth  morning  I  found  that  though  the 
temperature  had  been  even  a  little  higher  (103'),  and 
was  still  101°,  and  the  pulse  and  respiration  were 
respectively  120  and  Z6,  the  improvement  in  the 
physical  signs  was  still  more  marked. 

My  note  was,  "  Very  fair  resonance  behind,  even 
to  the  base ;  some  impairment  in  the  axillary  region 
from  the  posterior  to  the  anterior  axillary  line.  Over 
the  front,  resonance  good  as  far  as  the  nipple.  Over 
the  whole  lung  bubbling  sounds  can  be  heard,  moder- 
ately loud,  and  of  double  rhythm.  Cheeks  bright- 
coloured."  Between  6  o'clock  and  10  that  evening 
the  temperature  suddenly  fell  from  loi''  to  97°;  the 
crisis  had  arrived,  and  the  ice-belt  was  removed.  iVfter 
this,  convalescence  was  complete. 

It  must  be  allowed,  I  think,  that  in  this  case  the 


152    THE  ICEBAG  AS  A  THERAPEUTIC  AGENT 

ice  was  of  the  greatest  service  ;  it  is  hardly  too  much 
to  say  that  it  saved  the  patient's  life.  The  condi- 
tion on  the  seventh  day,  when  the  large  ice-belt  was 
applied,  was  most  alarming.  The  entire  right  lung 
was  consolidated,  and  the  dyspnoea,  the  cyanosis,  and 
the  "  prune-juice  "  expectoration  indicated  the  gravity 
of  the  prognosis.  Seventeen  hours  after  its  applica- 
tion a  distinct  improvement  was  observed  in  the 
sputum  and  in  the  hue  of  the  cheeks.  Next  day  a 
very  extensive  change  for  the  better  had  occurred  in 
the  physical  signs,  and  this  improvement  advanced 
rapidly.  It  had  attained  a  most  remarkable  degree 
before  the  crisis  occurred.  It  is  surely  uncommon  in 
pneumonia  for  manifest  improvement  in  physical 
signs  to  commence  thirty-six  hours  before  the  crisis, 
and  in  this  case  it  seemed  certainly  due  to  the  local 
influence  of  the  ice.  The  comparatively  low  range  of 
the  temperature  throughout  (after  the  ice  was  applied) 
should  also  be  noticed. 

Case   XVI. — Harry  D ,  seven   years   old,   an 

inmate  of  the  Highgate  Branch  of  the  Children's 
Hospital,  with  a  retracted  right  chest,  due  to  former 
empyema,  the  right  lung  being  entirely  collapsed  (as 
was  found  on  post-mortem  examination  some  months 
later),  was  taken  ill  on  22nd  June  1887.  I  saw  him 
next  day,  and  found  his  temperature  104°,  pulse  160, 
respiration  56.  Feeling  sure,  though  I  could  not 
prove,  that  pneumonia  of  the  left,  the  only  working, 
lung  was  commencing,  I  had  an  icebag  at  once  applied 
over  it.  The  temperature  fell  4°  before  the  next 
morning,  but  gradually  rose  again,  not  attaining  the 
same  height,  however,  for  forty-eight  hours.  On  the 
third  day  of  his  illness  I  detected  a  small  area  of 
dullness  over  the  root  of  the  left  lung,  and  at  this 
spot  bronchial  breathing.  He  complained  of  pain  at 
the  epigastrium,  and  I  noticed  that  his  lips  and  cheeks 


TWO  CASES  OF  PNEUMONIA  153 

were  already  livid.  This  was  not  surprising,  for  his 
other  lung  was  useless.  The  prognosis  was  evidently 
most  grave,  and  might  even  have  been  looked  upon 
as  hopeless.  Next  day,  the  fourth,  the  dullness  was 
more  extensive,  being  now  four  fingerbreadths  in 
diameter,  and  albuminuria  was  present,  but  the  com- 
plexion was  not  more  blue  than  yesterday,  and  the 
boy  seemed  a  little  stronger.  The  icebag  had  been 
persistently  applied.  Pulse,  1 60;  respiration,  60.  On 
the  fifth  day  the  dullness  was  decidtrdly  less,  measur- 
ing now  only  two  fingerbreadths,  and  the  temperature 
was  lower,  ranging  at  about  102° ;  pulse,  152  ;  respira- 
tion, 58.  Epigastric  pain  continued.  The  sixth  day 
resembled  the  fifth.  On  the  seventh  day  the  tempera- 
ture fell  to  normal,  and  the  icebag  was  removed. 

Pleuritic  friction  could  now  be  heard  over  the  dull 
area  and  below  it.  The  pleurisy  kept  his  temperature 
a  little  raised  for  a  few  days,  but  it  gradually  subsided 
without  effusion  of  fluid,  and  the  boy  returned  to  his 
condition  before  the  pneumonia.  By-and-by  he  was 
able  to  go  home,  but  three  months  later  he  came  back 
to  Great  Ormond  Street,  and  died  there  from  cardiac 
failure.  Post-mortem  examination  showed  that  the 
right  lung  was  completely  collapsed,  the  right  side  of 
the  heart  greatly  dilated,  and  the  tricuspid  valve 
incompetent,  the  left  auricle  and  ventricle  and  mitral 
valve  being  normal. 

The  left  lung  was  very  voluminous  ;  it  was  healthy 
except  for  some  very  old  cretaceous  and  calcified 
tubercle  at  its  apex ;  there  were  comparatively  rece7it 
pleuritic  adhesions  over  the  left  lower  lobe. 

In  this  case  it  is  hardly  possible  to  doubt  that  the 
icebag  saved  the  boy's  life  in  a  condition  otherwise 
hopeless. 

Since  the  publication  of  these  cases,  I  have  continued 
to  use  the  icebag  in  the  treatment  of  pneumonia,  and 


154    THE  ICEBAG  AS  A  THERAPEUTIC  AGENT 

am  satisfied  that  in  addition  to  its  beneficial  action  in 
the  reduction  of  temperature,  it  does  tend  to  check 
the  local  inflammation  of  the  lung.  And  no  difficulty 
need  be  felt  in  accepting  this  statement  on  the  ground 
that  pneumonia  is  a  specific  disease,  due  to  the 
presence  of  micro-organisms,  for  Dr  Burdon  Sander- 
son stated  in  his  Croonian  Lectures  [Bj'itish  Medical 
Journal,  28th  November  1891,  p.  1137)  that  "the 
pneumococcus  is  one  of  the  most  remarkable  micro- 
phytes known  ;  first,  because  under  certain  conditions 
it  is  so  extremely  virulent,  but  secondly,  because  it 
exemplifies  the  general  principle  that  virulence  is  one 
of  the  most  variable  attributes  of  a  microphyte — one 
which  is  most  affected  by  its  environment^  Hence  it 
is  readily  conceivable  that  an  alteration  in  the  environ- 
ment, produced  by  the  persistent  application  of  cold, 
may  be  a  powerful  factor  in  checking  the  growth  of 
the  specific  organism.  I  do  not,  of  course,  claim  that 
it  will  save  every  case  of  pneumonia :  many  of  those 
due  to  influenza  or  alcoholism,  or  of  septic  origin,  are 
hopeless  under  any  kind  of  treatment.  But  I  believe 
that  it  is  capable  of  saving  some  lives  which  would 
be  lost  if  fomentations  or  poultices  were  employed, 
that  it  reduces  the  severity  of  symptoms,  relieves 
pain,  gives  comfort  to  the  patient,  and  brings  about 
an  earlier  and  a  more  rapid  convalescence.  The 
relief  of  pain  is  often  very  striking,  and  not  unfre- 
quently,  after  the  removal  of  the  ice-bag,  patients  ask 
for  its  re-application,  on  account  of  the  comfort  they 


USEFULNESS  IN  PLEURISY  155 

experience  from  its  presence,  A  few  months  ago  I 
saw,  in  consultation,  a  lady  of  62  suffering  from  pneu- 
monia, whose  condition  was  critical,  and  growing 
worse.  With  some  reluctance,  on  account  of  her  age, 
I  suggested  that  the  poultices  should  be  replaced  by 
an  icebag,  and  I  arranged  to  see  her  again  three 
hours  later  to  watch  the  effect.  The  change  was 
carried  out,  and  to  my  inquiry  how  she  liked  the  ice, 
she  replied  with  emphasis,  "  It's  delicious  !'^  When  I 
removed  the  ice  in  order  to  examJne  her  chest  she 
exclaimed,  "  I  must  have  my  bag  again  !  "  Her  im- 
provement commenced  with  the  application  of  the 
ice,  and  she  was  soon  convalescent. 

In  acute  pleurisy,  apart  from  pneumonia,  the  icebag 
is  often  very  helpful ;  it  quickly  relieves  pain,  and 
has  often  seemed  to  cut  short  the  disease.  Its  action 
may  be  aided  by  tightly  strapping  the  affected  side, 
so  as  to  restrain  the  movements  of  respiration,  the 
bag  or  bags  containing  ice  being  then  applied  over  the 
strapping.  If  the  symptoms  are  very  acute  it  is 
useful  to  commence  the  treatment  by  the  application 
of  a  few  leeches.  When  a  serous  effusion  has  occurred 
into  the  pleural  cavity,  before  the  case  came  under 
treatment,  I  have  seen  the  use  of  an  icebag  apparently 
of  great  service  in  hastening  absorption. 

Pericarditis  I  find  as  amenable  as  pleurisy  to  the 
local  influence  of  ice,  and  I  have  related  seven  cases 
thus  treated  in  a  paper  read  at  the  Nottingham  meet- 
ing  of  the   British    Medical    Association.      Pain    is 


156    THE  ICEBAG  AS  A  THERAPEUTIC  AGENT 

rapidly  relieved,  the  extent  and  loudness  of  the 
friction-rub  quickly  diminish,  and  effusion  is  checked. 
The  pulse  becomes  stronger  and  less  frequent,  the 
dyspnoea  lessens,  and  it  is  clear  that  the  local  influ- 
ence of  ice  on  the  heart  in  pericarditis  is  not  de- 
pressant, but  decidedly  tonic.  In  conversation 
recently  with  Dr  Leech,  Professor  of  Therapeutics 
in  the  Victoria  University,  I  was  interested  to  find 
that  he  also  had  observed,  and  was  much  impressed 
by,  this  tonic  influence  of  the  icebag  in  pericarditis. 

I  have  even  seen  a  recent  pericardial  effusion  rapidly 
absorbed  beneath  an  icebag :  in  this  case  the  diminu- 
tion of  the  increased  precordial  dullness  was  distinctly 
made  out  within  a  few  hours  after  the  application  of 
the  ice,  and  it  steadily  continued.  In  pericarditis  it 
is  impossible  to  explain  the  improvement  caused  by 
the  ice  as  being  due  to  mere  reduction  of  temperature  ; 
for  in  pericarditis  this  is  often  not  much  raised,  and 
it  is  sometimes  very  little  depressed  by  the  icebag 
which  produces  so  much  improvement  in  the  physical 
signs.  And  if  it  be  true  that  the  local  application  of 
ice  does  diminish  the  violence  of  a  pericarditis,  it  is  a 
fact  of  the  greatest  possible  importance  in  practice. 
Pneumonia,  on  recovery,  leaves  the  lung  little  the 
worse,  but  pericarditis  is  apt  to  involve  and  damage 
the  muscular  structure  of  the  heart,  causing  perma- 
nent dilatation  of  the  cardiac  cavities,  especially  of  the 
right  ventricle ;  and  a  case  of  "  cured  pericarditis  "  is, 
in  very   many    instances,  a   case   of  crippled    heart 


USEFULNESS  IN   PERICARDITIS  157 

Hence  it  is  of  the  first  importance  to  arrest  a  peri- 
carditis as  soon  as  possible,  and  from  this  point  of 
view  I  believe  that  the  use  of  ice  will  be  found  a  very 
great  gain.  Experience  is  as  yet  too  limited  to 
warrant  any  definite  statement  about  the  after-history 
of  these  cases  ;  but,  from  what  I  have  already  seen, 
I  feel  confident  that  it  will  be  found  in  the  future 
that  the  use  of  ice  in  the  treatment  'df  a  case  of  peri- 
carditis will  often  have  the  result  of  preventing  the 
loss  of  many  years  of  the  patient's  life. 

With  regard  to  peritonitis  I  have  little  to  say,  but 
I  will  point  out  that  the  local  application  of  an  ice-bag 
is  often  of  great  benefit  in  the  less  acute  inflamma- 
tions of  the  vermiform  appendix  ("  perityphlitis  "),  In 
the  more  severe  cases  of  this  kind,  where  decided 
symptoms  of  peritonitis  are  present,  no  time  should 
be  lost  in  any  palliative  treatment,  for  such  cases  are 
generally  the  result  of  the  perforation  of  the  appendix 
by  a  concretion,  or  of  a  local  gangrene,  and  if  not 
operated  on  are  rapidly  fatal.  I  have  had  five  cases 
of  this  kind  under  my  care  during  the  last  three 
years :  the  first  was  not  operated  on,  and  died  in 
three  days  from  the  earliest  symptoms  ;  the  other 
four  were  submitted  to  operation  within  a  few  hours 
after  admission  to  hospital.  All  of  them  were  found 
to  have  the  condition  above  described ;  all  four  re- 
covered rapidly  and  completely.  (See  Cliiiical  Trafis- 
actiofis,  1892,  p.  135.) 

But  where  the  inflammation  of  the  appendix  is  less 


158    THE  ICEBAG  AS  A  THERAPEUTIC  AGENT 

acute,  the  local  application  of  ice  often  produces  very 
rapid  relief  of  pain  and  diminution  of  the  swelling. 
Any  one  who  watches  the  effect  of  the  icebag  on  this 
purely  local  inflammation  will  be  prepared  to  accept 
its  local  influence  in  pericarditis  and  in  pneumonia. 

In  catarrhal  laryngitis  the  icebag  quickly  reduces 
the  congestion,  and  thus  diminishes  the  urgent  symp- 
toms ;  even  in  diphtheritic  laryngitis  it  sometimes 
has  given  distinct  relief. 

It  is  not  necessary  for  me  to  advocate  the  employ- 
ment of  the  ice-bag  in  meningitis,  but  I  should  like  to 
mention  a  case  of  posterior-basic  meningitis  in  a 
young  girl  recently  under  my  care  at  the  Hospital 
for  Sick  Children,  in  which  ice,  applied  to  the  occiput 
and  nape  of  the  neck,  had  more  influence  in  checking 
obstinate  vomiting  than  all  the  drugs  and  other  means 
which  were  used. 

In  infantile  paralysis,  if  seen  within  forty-eight 
hours  after  the  onset,  an  icebag  applied  over  the 
affected  region  of  the  spine  may  be  expected  to  render 
good  service.  It  is  not  often  that  these  cases  are 
brought  to  a  hospital  sufficiently  early  to  give  this 
treatment  a  chance,  but  I  can  remember  one  case  at 
least  in  which  it  was  apparently  very  successful,  the 
resulting  paralysis  being  very  limited. 

I  will  say  nothing  of  the  employment  of  ice  in  the 
treatment  of  orchitis,  and  of  some  cases  of  hernia,  for 
of  this  I  have  no  experience ;  but  I  must  not  omit  to 
point  out  the  benefit  which  may  be  obtained  from  it 


USEFULNESS  IN  SCIATICA  159 

in  recent  cases  of  sciatica.  It  is  now  well  understood 
that  sciatica  is  usually  not  a  neuralgia  but  a  neuritis, 
that  it  is  due  to  a  local  affection  of  the  nerve  trunk. 
Hence,  it  is  not  unreasonable  to  expect  that  an  icebag 
applied  over  the  inflamed  part  may  do  good.  On 
two  or  three  occasions  I  have  seen  very  rapid 
improvement  produced  in  this  way.  One  such  case  I 
will  briefly  narrate  : — 

Thomas    A ,    27,    printer,    admitted    into    St 

Mary's  Hospital  2nd  July  1890,  for  sciatica  of  twelve 
days'  duration.  On  the  19th  of  June  he  had  sat  on  a 
wet  seat  outside  an  omnibus :  the  sciatica  began  next 
day.  On  admission,  pain  worst  behind  trochanter, 
passing  down  thigh  and  leg  to  the  foot.  Says  this 
limb  feels  numb.  He  has  already  had  four  blisters, 
but  these  have  given  no  relief  An  icebag  was  applied 
behind  the  trochanter.  The  next  day  (3rd  July) 
improvement  was  noted  ;  there  was  less  pain,  and  less 
tenderness  where  the  ice  had  been.  A  second  icebag 
was  placed  over  the  nerve  lower  down.  In  five  days 
(7th  July)  he  was  nearly  well ;  the  tenderness  behind 
the  trochanter  and  behind  head  of  fibula  had  vanished  ; 
still  "a  little  sore"  over  gluteal  region  above  the 
trochanter.  The  patient  was  allowed  to  get  up,  and  a 
belladonna  plaster  applied.  On  12th  July  he  was 
"  quite  well." 

Where  the  sciatica  has  lasted  for  several  weeks  one 
can  hardly  expect  much  benefit  from  the  icebag,  yet 
I  have  seen  it  give  marked  relief  (not  cure)  in  a  case 
of  three  months'  standing,  the  patient  having  been 
in   bed   for   a   fortnight,   and    having  had   morphine 


160    THE  ICEBAG  AS  A  THERAPEUTIC  AGENT 

injections  three  times,  acupuncture  three  times,  and 
eighteen  flying  blisters — all  without  benefit.  The 
application  of  ice  quickly  "  deadened  "  the  pain,  and 
enabled  him  to  sleep.  The  improvement  continued, 
and  further  benefit  was  obtained  by  massage. 

In  inflammatory  conditions  of  the  eye  the  value  of 
iced  applications  is  now  generally  recognised.  My 
colleague,  Mr  Silcock,  informs  me  that  they  give  the 
greatest  relief  in  some  cases  of  iritis  and  cyclitis,  and 
that  they  are  frequently  employed  as  a  means  of 
mitigating  the  severity  of  iritis  after  operations  for 
cataract. 

I  may  add  a  few  words  about  the  difficulties  that 
may  be  encountered  in  endeavouring  to  use  this 
method  of  treatment.  In  country  districts  it  may  be 
impossible  to  procure  a  supply  of  ice  in  summer ;  in 
towns  it  may  always  be  obtained  from  a  fishmonger. 
The  block  of  ice  needs  to  be  broken  up  into  small 
masses  ;  this  can  easily  be  effected  by  means  of  a 
hammer  and  a  pin.  If  an  icebag  is  not  at  hand,  it  is 
usually  possible  to  obtain  a  waterproof  sponge-bag. 
Two  or  three  new  sponge-bags  should  be  procured, 
and  the  larger  the  better  ;  as  a  rule,  two  such  bags  are 
needed  at  once.  When  the  bag  has  been  loosely  filled 
with  small  masses  of  ice,  its  mouth  must  be  firmly 
tied,  in  order  to  prevent  any  escape  of  water.  It  is 
sometimes  almost  impossible  to  hinder  this  altogether, 
but  a  soft  absorbent  towel  may  be  placed  all  round 
the  bag.     This  difficulty  led   me  to  give  a  trial  to 


METHOD  OF  APPLICATION  161 

Leiter's  coiled  tubes,  but  I  found  them  irksome  to  the 
patient,  and  not  so  efficient. 

Another  difficulty  is  that  of  keeping  the  icebag  in 
its  proper  position,  especially  when  the  patient  turns 
in  bed.  Any  such  movement  is  apt  to  displace  the 
bag  from  its  contact  with  the  wall  of  the  thorax,  and 
sometimes  to  invert  it,  and  thus  favour  the  escape  of 
water  and  wetting  of  the  bed-clothes.  Often  it  is 
possible  to  prevent  these  undesirable  results  by  fixing 
the  bag  in  its  proper  position  by  a  few  turns  of  a  light 
bandage,  but  if  there  is  much  dyspnoea  this  may  not 
be  possible,  and  we  must  then  rely  on  the  carefulness 
and  skill  of  the  nurse,  who  will  alter  the  position  of 
the  icebag  when  the  patient  moves  in  bed.  This 
difficulty  is  less  serious  than  might  be  imagined, 
because  the  soothing  effect  of  the  cold  applications 
diminishes  restlessness,  and  enables  the  patient  to  lie 
more  quietly. 

If  there  is  great  local  tenderness  which  resents  even 
the  light  pressure  of  the  icebag,  suspension  should  be 
tried,  but  in  this  case  the  nurse  must  take  especial 
care  to  see  that  the  suspended  bag  is  kept  actually  in 
contact  with  the  surface. 

There  is  not  usually  any  difficulty  in  persuading 
patients  to  allow  the  application  of  an  ice-bag,  and 
after  trying  it  for  a  time  they  are  generally  well 
pleased  with  it.  Twice  I  have  known  it  to  be  thrown 
off  after  a  few  minutes,  in  the  delirium  of  pneumonia, 
and   occasionally   the   patient   has   objected    to    the 

L 


162    THE  ICEBAG  AS  A  THERAPEUTIC  AGENT 

constraint  of  position  which  it  had  involved,  and 
which  might  probably  have  been  avoided  if  he  had 
been  the  sole  charge  of  the  nurse  ;  but  as  a  rule  the 
icebag  gives  comfort,  and  often  it  affords  great  relief 
I  can  remember  only  one  patient  who,  though  doing 
well,  objected  to  the  treatment  throughout. 

There  may  sometimes  be  greater  difficulty  in 
private  practice  in  persuading  the  friends  of  the 
patient  to  sanction  the  use  of  treatment  so  opposed  to 
traditional  notions,  but,  as  a  matter  of  fact,  I  have  not 
in  consulting  practice  found  this  to  be  a  real  difficulty. 
Still  there  is  no  doubt  that  the  general  practitioner 
must  act  warily  in  such  a  matter,  and  must  remember 
that  if  recovery  does  not  follow,  he  may  be  unjustly 
blamed. 

Any  real  harm  from  the  use  of  icebags  may  always 
be  avoided  by  efficient  nursing.  In  the  case  of  an 
infant  or  young  child  the  temperature  should  be  taken 
hourly,  and  the  icebag  removed  when  the  temperature 
falls  to  100  ,  and  replaced  when  it  again  rises  to  102^. 
At  the  same  time  the  child's  legs  and  feet  should  be 
wrapped  in  hot  moist  flannels,  and  it  may  even 
be  desirable  to  apply  warm  fomentations  to  the 
abdomen. 

In  adults  also  similar  applications,  or  a  hot-water 
bottle  to  the  feet,  are  often  of  service,  and  dilatation 
of  the  cutaneous  blood-vessels  may  be  brought  about 
by  the  use  of  such  remedies  as  jaborandi,  alcohol,  and 
nitro-glyccrine. 


PRECAUTIONS  163 

Special  care  must  of  course  be  exercised  in  the  use 
of  ice  for  aged  or  debilitated  patients.  But  the  case 
above  narrated  of  the  lady  of  62,  who  found  the 
icebag  "  delicious,"  shows  that  even  at  this  period  of 
life  benefit  may  be  derived  from  its  employment. 
And  even  in  such  depressed  conditions  as  influenza  or 
alcoholism,  it  is  possible  to  use  this  form  of  treatment 
with  advantage  ;  and  my  friend  J)r  Sansom,  of  the 
London  Hospital,  lately  told  me  of  some  apparently 
quite  hopeless  cases  of  alcoholic  pneumonia  under  his 
care  which  had  recovered  after  treatment  with  ice. 

In  such  conditions  the  subcutaneous  injection  of 
strychnine  will  be  found  of  considerable  assistance, 
commencing  with  2  minims  of  the  official  solution 
three  times  daily,  and  pushing  up  the  dose  to 
6  or  8  minims,  if  no  twitching  of  muscles  is 
observed. 

The  length  of  time  for  which  the  use  of  the  icebag 
should  be  continued  in  any  particular  case,  must  be 
decided  by  the  progress  of  the  disease  and  the  general 
condition  of  the  patient 

Sometimes  it  "is  desirable  to  use  it  for  a  few  hours, 
and  then  remove  it  for  an  interval  longer  or  shorter, 
as  the  symptoms  may  suggest.  Thus  it  may  be 
applied  for  four  hours,  then  removed  for  a  like  period, 
and  then  again  applied,  and  so  on.  Or  it  may  be 
used  for  longer  periods  during  the  day,  and  removed 
at  night.  Each  case  demands  a  sound  judgment  on 
the  part  of  the  physician.     Sometimes  it  ma}-  be  con- 


164    THE  ICEBAG  AS  A  THERAPEUTIC  AGENT 

tinuously  applied  for  a  considerable  period,  such  as 
two  or  three  days  or  even  longer,  without  inter- 
mission. 

Thus,  in  one  of  the  cases  of  pericarditis  above 
referred  to,  the  subject  of  which  was  a  girl  of  7 
years  of  age,  the  icebag  was  kept  in  position  over  the 
heart  during  the  greater  part  of  twelve  days,  in  fact 
during  186  out  of  the  288  hours,  commencing  with  a 
continuous  application  of  62  hours  :  the  child  liked 
the  icebag,  and  the  final  result  was  most  satisfactory. 

The  employment  of  this  remedy  no  .doubt  calls  for 
care  and  watchfulness  on  the  part  of  both  nurse  and 
physician,  but  with  reasonable  caution  it  involves  no 
risk,  and  it  is  capable  of  rendering  the  most  effectual 
service. 


A  CLINICAL  LECTURE  ON  A  CASE  OF 
CHOREA  AND  PERICARDITIS;  A  CASE 
OF  GENERAL  PARALYSIS  OF  THE 
INSANE;  A  CASE  OF  MITRAL  DISEASE 
WITH  SPASMODIC  DYSPNOEA;  AND  A 
CASE  OF  CARDIAC  DILATATION. 

( Clinical  Journal^  1893.) 

Case  I. — Chorea.  Absent  Knee-jerk.  Pericarditis. — 
This  little  girl  was  admitted  on  17th  January  1893, 
suffering  from  chorea  of  moderate  severity.  The 
first  point  worth  noticing  about  her  is  that  the  knee- 
jerks  were  absent.  This  condition  is  occasionally 
found  in  chorea,  sometimes  in  quite  mild  cases,  and  I 
am  inclined  to  think  that  it  is  evidence  of  some  toxic 
influence  acting  on  the  nerves  or  nerve-centres, 
analogous  to  that  which  undoubtedly  is  present  in 
diphtheritic  paralysis,  and  frequently  in  cases  of 
diphtheria  without  paralytic  symptoms.  It  suggests 
that  the  chorea  itself  may  be  due  to  a  blood-poison 
acting  on  the  cortical  motor  cells.  The  next  point  has 
reference  to  the  heart.  There  was  a  systolic  murmur 
at  the  apex,  but  the  impulse  was  normal.  Such  a 
murmur  in  choreic  children  may  be  of  a  temporary 
character,  disappearing  with  the  chorea.  No  history 
of  rheumatism  could  be  obtained,  and  there  were  no 

H>5 


166  CHOREA  AND  PERICARDITIS 

definite  symptoms  of  this  disease,  that  is  to  say,  there 
was  no  joint  affection,  no  nodules  to  be  found  in  the 
usual  situations,  no  erythema,  and  no  tonsillitis.  It 
was  somewhat  vaguely  stated  that  her  mother  had 
suffered  from  "  rheumatics."  Such  a  statement,  how- 
ever, is  but  slight  evidence  of  rheumatism,  since 
"  rheumatics  "  is  a  term  loosely  used  by  women  in  her 
position  of  life.  No  other  member  of  the  child's 
family  had  suffered  from  rheumatism.  So  far,  then, 
there  was  no  definite  family  history  of  rheumatism, 
and  unless  we  assume  that  the  chorea  and  the  endo- 
cardial murmur  are  to  be  regarded  as  manifestations 
of  this  complaint,  there  is  no  evidence  of  past  or 
present  rheumatism  in  the  child. 

It  was  stated  that  she  had  experienced  a  severe 
fright,  but  further  inquiry  elicited  the  fact  that  this 
took  place  some  months  before  the  appearance  of 
chorea ;  it  could  not,  therefore,  have  been  the  cause. 

The  choreic  symptoms  improved  and  almost 
vanished ;  but  about  a  month  after  admission  she 
developed  pericarditis  ;  the  temperature  suddenly 
shot  up  to  103",  a  pericardial  friction-sound  could  be 
heard,  and  difficulty  of  breathing  came  on,  soon 
amounting  to  orthopnoea. 


This  case,  then,  is  an  instance  of  a  child  with 
chorea,  in  which  the  prominent  heart-lesions  of 
rheumatism  were  found  without  any  other  rheumatic 
signs.  It  is  important  to  remember  that  it  is  by  no 
means  uncommon  for  children  to  have  acute  rheu- 
matism manifested  by  the  presence  of  little  or  nothing 
but  the  cardiac  lesions  due  to  this  disease.  It  is  also 
desirable  to  note  that  of  the  two  lesions  pericarditis  is 
of  infinitely  more  immediate  importance  than  endo- 


DILATATION  OF  HEART  167 

carditis.     Later  on,  the  valvular   lesions  become  of 
moment,  owing  to   the   various   other   organic  con- 
ditions they  produce,  but  at  their  onset  they  are  not 
of  such  grave  import  as  pericarditis.     For  pericarditis 
causes  an  acute  dilatation  of  the  heart,  especially  of 
the  thin-walled  right  cavities,  by  the  injurious  effect 
of  the  inflammation  on  the  muscular  structure.     This 
dilatation  can  easily  be  demonstrated  by  the  increase 
in  the  precordial  dullness  which  it  causes   at  a  very 
early  stage  of  the  disease,  while  as  yet  the  rub  can  be 
distinctly  heard  over  a  large  part  of  the  heart,  while 
the  impulse  can  be  well  felt,  and  it  is  clear  that  no 
great  amount  of  fluid    is  present  in  the  pericardial 
cavity.     And  this  dilatation  is  only  too  apt  to  be  per- 
manent, partly  from  the  effect  of  adhesions,  but  yet 
more  from  the  weakening  of  the  muscular  wall,  espe- 
cially of  the  right  ventricle.     A  case  of  "  cured  "  peri- 
carditis will  often  be  found  to  have  a    considerable 
increase  of  precordial  dullness,  and    a   rapid    pulse, 
usually  about  120  to  the  minute.     A  child  generally 
recovers    from    its  first  attack  of   pericarditis,  but  a 
second  or  a  third  attack  increases  the  damage  to  the 
structure  of  the  heart  to  such  an  extent  as  soon  to 
cause  a  fatal  issue.     In  children,  it  is  pericarditis  that 
kills. 

If,  therefore,  a  child  presents  the  slightest  evidence 
of  rheumatism  of  any  kind,  whether  arthritis  (even 
the  most  subacute),  or  chorea,  or  nodules,  or  erythema, 
or  tonsillitis,  the  heart  must  be   most  carefully  and 


168  CHOREA  AND  PERICARDITIS 

frequently  examined,  lest   pericarditis  should  escape 
observation. 

To  return  to  this  case.  As  soon  as  the  pericarditis 
was  noticed,  she  was  put  upon  salicylates,  and  an  ice- 
bag  was  applied  to  the  precordium,  in  accordance 
with  the  plan  of  treatment  I  have  elsewhere 
advocated.*  In  two  days  the  signs  had  considerably 
diminished  ;  the  area  of  cardiac  dullness  was  less,  the 
friction-sound  much  less  distinct,  and  the  breathing 
easier.  On  the  third  day,  as  the  temperature  had 
fallen  to  g6",  I  thought  it  wise  to  discontinue  the  ice- 
bag.  A  day  or  two  later  the  friction-sound  increased 
in  intensity,  and  the  temperature  rose  again.  The 
icebag  was  re-applied  for  an  hour  or  two  at  a  time. 
On  the  fifth  day  the  temperature  rose  to  102.5°,  ^^^d 
the  dyspnoea  recurring,  four  leeches  were  applied. 
When  I  saw  her  the  next  morning  she  was  in  great 
distress ;  the  cardiac  dullness  extended  two  finger- 
breadths  to  the  right  of  the  sternum,  and  a  loud  rasp- 
ing double  rub  could  be  heard.  I  had  the  icebag 
re-applied,  and,  with  a  view  of  preventing  collapse, 
kept  the  rest  of  the  body  warm  by  means  of  three 
hot-water  bottles  applied  simultaneously,  one  to  the 
feet,  and  one  on  each  side  of  her.  In  twenty-four 
hours  the  friction-sound  was  much  less  loud,  and  the 
increase  of  the  heart's  area  to  the  right  of  the  sternum 
was  considerably  diminished.  To-day,  the  fifth  day 
since  the  re-application  of  the  icebag,  the  area  of  dull- 
ness is  about  one  fingerbreadth  to  the  right  of  the 
sternum,  and  it  extends  about  the  same  amount  to 
the  outer  side  of  the  left  nipple-line,  upwards  to  the 
upper  margin  of  the  third  cartilage.  The  rub  is  now 
quite  faint,  and  this  is  not  owing  to  effusion  of  fluid, 

■^  See    T/ic   Cliincal  Jotu^nal^  vol.    i.,    No.    i  ;   also,  British 
Medical  Journal,   i8th   February  1893. 


TREATMENT  169 

for  not  only  has  the  area  of  duHness  diminished,  but 
the  heart's  impulse  can  be  well  felt  over  a  considerable 
area.  There  is  now  a  short,  cantering,  presystolic 
murmur  in  addition  to  the  louder  systolic  murmur 
which  has  been  present  throughout,  and  which  is  now 
conducted  into  the  axilla.  The  pulse-rate,  which  was 
1 66  before  the  re-application  of  the  icebag,  fell  within 
a  few  hours  to  132,  and  is  to-day  106  per  minute. 
The  child  is  obviously  better.  There  is  no  orthopnoea, 
and  but  little  dyspnoea.  She  has,  nearly  lost  her 
pain,  sleeps  well,  and  plays  with  her  toys  and  picture- 
book.  The  icebag  is  still  on,  and  to  its  use  I  attribute 
the  very  marked  improvement  which  has  taken  place. 

This  treatment  is  of  special  value  in  the  early  and 
acute  stages  of  pericarditis.  It  is  true  that  a  patient 
thus  treated  needs  very  careful  watching;  but  provided 
that  the  general  warmth  of  the  body  is  kept  up,  as  in 
this  case,  by  means  of  hot-water  bottles,  there  seems 
to  be  no  risk.  The  temperature  should,  however,  be 
frequently  taken,  and  the  patient  watched  for  signs 
of  collapse.  In  the  later  attacks  of  pericarditis  the 
application  of  ice  is  much  less  useful,  and  much  more 
likely  to  produce  collapse. 

Case  II. — General  Paralysis  of  the  Insane,  with 
mainly  Physical  Symptoms. — This  man,  37  years  of 
age,  is  interesting  from  a  diagnostic  point  of  view. 
He  has  been  employed  in  the  merchant  service,  and 
was  lately  captain  of  a  large  vessel.  With  the  excep- 
tion of  syphilis  when  about  19,  he  has  always  enjoyed 
good  health.  He  has  recently  had  a  great  deal  of 
mental  anxiety  as  regards  his  pecuniary  and  domestic 
affairs.     In    May  last,  the  ship   he  commanded  was 


170    GENERAL  PARALYSIS  OF  THE  INSANE 

wrecked.  In  the  gale  which  caused  her  loss  he  had 
been  exposed,  and  without  sleep,  for  fifty-eight  hours, 
as  he  dared  not  leave  his  post  on  deck.  Since  this 
misfortune  he  has  been  unable  to  obtain  employment. 
He  returned  to  England  in  the  autumn.  Some  little 
time  afterwards  he  began  to  suffer  from  pains  in  the 
head,  and  noticed  that  his  memory  was  becoming 
impaired.  Lately  he  has  had  some  trouble  in  walk- 
ing, and  has  double  vision  on  looking  to  the  right. 
For  this  last  symptom  he  went  to  the  Moorfields 
Ophthalmic  Hospital,  where  he  saw  my  colleague, 
Mr  Silcock,  who  diagnosed  his  condition  and  kindly 
sent  him  on  to  me  yesterday. 

As  there  has  been  some  difficulty  in  walking,  we 
proceed  first  to  watch  his  gait.  You  can  see  at  once 
that  it  is  unsteady,  that  there  is  distinct,  though  not 
great,  ataxy.  This  becomes  more  definite  if  he  walks 
with  his  eyes  closed,  and  on  sharply  turning  round  he 
totters.  When  placed  with  his  feet  close  together  he 
can  stand,  even  with  closed  eyes,  but  the  movements 
of  the  tendons  on  the  dorsum  of  his  feet  betray  his 
insecurity.  There  is  defect  of  co-ordination  of  the 
upper  limbs  also,  for  he  quite  fails  to  make  the  tips  of 
his  forefingers  meet,  even  when  he  looks  at  them,  and 
the  failure  is  still  more  evident  when  his  eyes  are 
closed. 

His  pupils  are  unequal.  They  both  contract  a  little 
with  accommodation,  but  you  can  see  that  the  con- 
traction is  sluggish,  and  the  pupil  soon  dilates  again. 
To  light,  there  is  little  or  no  movement  of  the  pupils. 
Movements  of  the  eyeball  show  that  there  is  weakness 
of  both  external  recti  muscles.  The  optic  discs  are 
pale,  but  otherwise  normal. 

When  he  is  told  to  show  his  upper  teeth,  you  note 
that  the  muscular  movement  is  tremulous  and  im- 
perfect at  first,  and  that  after  one  or  two  attempts  this 
imperfect  movement  becomes  impossible.     Similarly, 


WITH  MAINLY  PHYSICAL  SYMPTOMS      171 

hu  can  whistle  for  a  moment,  but  the  muscular  effort 
of  the  lips  soon  fails.  The  tongue  is  protruded, 
straight ;  it  is  not  atrophied,  and  is  hardly  at  all 
tremulous. 

You  have  no  doubt  noticed  the  indistinctness  of  his 
speech  as  he  answered  my  questions  :  it  became  more 
and  more  marked  as  he  told  his  tale.  There  is  weak- 
ness of  articulatory  power,  increasing  as  he  talks, 
the  tongue  apparently  being  weaker  than  the  lips,  for 
labials  are  fairly  pronounced,  while  the  tongue-sounds 
are  imperfect. 

Now  let  us  examine  the  condition  of  his  limbs. 
Y^ou  see  that  he  feels  instantly,  and  localises  correctly, 
the  slightest  touch  on  the  skin  of  his  lower  limbs,  and 
that  if  I  move  one  of  them  without  allowing  him  to 
see  what  I  do,  he  tells  me  at  once  which  I  have  moved, 
and  in  which  direction.  He  does  not  complain  of 
pains,  or  of  any  other  subjective  sensation.  You  see 
also  that  the  nutrition  of  his  muscles  is  good  ;  there  is 
nowhere  any  atrophy.  If  you  test  the  power  of  the 
flexors  and  extensors  of  his  knees,  you  find  that  they 
are  strong,  and  can  overcome  considerable  resistance. 
The  muscles  are  not  flabby  ;  on  the  contrary,  they  feel 
too  firm,  their  tone  is  somewhat  too  great,  and  the 
effect  of  this  is  seen  when  we  proceed  to  test  his  knee- 
jerks.  On  the  right  side  we  at  once  find  a  marked 
increase  in  the  jerk,  but  on  the  left  side  there  is  at 
first  a  great  difficulty  in  obtaining  it  at  all.  We  must 
not  conclude  that  it  is  absent,  for  you  will  see  that  the 
limbs  are  slightly  rigid,  and  that  the  patient  never 
thoroughly  relaxes  his  muscles.  Even  the  device  of 
making  the  patient  interlock  his  fingers  and  pull 
forcibly  fails  to  relax  his  leg-muscles  while  he  is  in  a 
recumbent  position  ;  but  now  that  we  have  made  him 
sit  in  a  chair,  and  cross  one  leg  over  the  other,  we 
succeed  in  a  favourable  moment  in  demonstrating 
marked    increase    of   the    knee-jerk    on    both    sides. 


172    GENERAL  PARALYSIS  OF  THE  INSANE 

There  is  a  slight  tendency  to  ankle  clonus  on  both 
sides,  and  the  plantar  reflexes  are  exaggerated. 


What  diagnosis  do  we  form  in  this  case  ?  At  first 
the  ataxia  and  inco-ordination,  and  some  of  the  eye 
symptoms,  suggest  tabes  dorsalis.  But  the  exaggera- 
tion of  the  knee-jerks  and  the  absence  of  all  sensory 
symptoms  are  against  this.  The  rigidity  and  in- 
creased reflexes  suggest  lateral  sclerosis,  but  the  good 
muscular  power  shows  that  this  cannot  be  far 
advanced.  We  have  then  symptoms  of  both  these 
conditions,  and  so  far  as  the  spinal  cord  symptoms  are 
concerned,  we  might  regard  the  case  as  one  of  "  ataxic 
paraplegia,"  that  is  to  say,  one  in  which  both  the 
lateral  and  the  posterior  columns  are  affected.  But 
there  is  evidently  some  cerebral  mischief  also,  as  evi- 
denced by  imperfect  articulation,  weakness  of  lower 
facial  muscles,  and  loss  of  memory.  We  have  to  deal 
here  with  a  very  wide  range  of  symptoms,  and  in  all 
probability  we  have  not  yet  learned  them  all.  For  we 
have  still  to  inquire  from  his  friends  whether  he  has 
not  during  the  past  few  months  shown  marked  deterio- 
ration of  mental  power,  and  perhaps  also  of  moral 
character,  which  may  be  quite  as  important  from  the 
diagnostic  point  of  view  as  are  the  physical  symptoms 
which  we  see  for  ourselves. 

Such  psychical  symptoms  as  these  would  throw  a 
clear  light  on  the  meaning  of  his  physical  condition. 
If,  in  addition,  delusions  of  grandeur  were  present. 


SYMPTOMS  AND  CAUSATION  173 

the  diagnosis  would  be  quite  obvious,  but  he  appears 
to  be  entirely  free  from  them.  Such  delusions,  how- 
ever, are  not  a  necessary  part  of  the  disease  known  as 
general  paralysis  of  the  insane;  and  judging  from  his 
physical  symptoms,  from  his  impairment  of  memory, 
and  his  general  appearance,  there  can  be  little  doubt 
as  to  the  nature  of  his  disease.  A  cerebral  tumour 
might  cause  the  loss  of  memory,  the  p^ins  in  the  head, 
and  some  defect  of  speech,  but  it  would  probably  cause 
optic  neuritis,  and  it  could  not  produce  this  peculiar 
combination  of  spinal  symptoms.  These  in  their  turn 
might  be  produced  by  insular  sclerosis,  but  then  there 
would  be  oscillating  tremor  of  the  upper  limbs  during 
movement,  nystagmus,  and  a  quite  different  affection 
of  speech. 

The  causation  of  his  disease  is  clear  enough.  The 
mental  and  physical  strain  of  commanding  a  vessel  in 
a  violent  gale,  with  no  sleep  and  little  food  for  fifty- 
eight  hours,  followed  by  the  exposure  and  anxiety 
caused  by  the  shipwreck,  the  disastrous  effect  on  his 
own  fortunes,  together  with  pecuniary  losses  entailed 
by  family  difficulties,  are  in  themselves  sufficient  to 
account  for  his  condition.  But  in  addition  to  this 
there  is  the  history  of  syphilis.  It  is  now  quite  certain 
that  syphilis  leaves  behind  it  a  predisposition  to  all 
kinds  of  degenerative  affections  of  the  central  nervous 
system.  The  patient  thinks  that  his  syphilis  was 
quite  got  rid  of  by  iodide  of  potassium,  but  he  does 
not  know,  as  we  do,  that  long  after  an  apparent  cure, 


174  SPASMODIC  DYSPNCEA  IN  MITRAL  STENOSIS 

perhaps  twenty  or  thirty  years  after,  syphilis  claims 
its  victim.  The  man  who  has  once  had  syphilis  is 
never  safe. 

Case  1 1 1. — Spasmodic  Dyspnoea  in  Mitral  Disease. — 
This  girl  has  mitral  regurgitation,  with  some  stenosis 
and  probably  an  adherent  pericardium,  the  results  of 
a  former  attack  of  rheumatism,  in  which  she  had 
endocarditis  and  pericarditis.  The  point  of  special 
interest  in  her  case  is  that  she  has  occasional  attacks 
of  spasmodic  dyspnoea  and  cardiac  pain  coming  on 
rapidly  and  unexpectedly,  and  lasting  a  variable  time, 
from  half  an  hour  to  two  or  three  hours. 

Such  attacks  are  not  very  rare  in  mitral  disease, 
especially  in  mitral  stenosis,  and  they  seem  to  be 
analogous  to  the  attacks  of  angina  which  are  apt  to 
occur  when  there  is  disease  of  the  aortic  valves.  They 
commence  without  warning  by  dyspnoea,  which  rapidly 
increases.  After  ten  or  fifteen  minutes  pain  is  felt  over 
the  cardiac  region.  The  dyspnoea  and  pain  continue 
until  the  attack  subsides.  The  patient's  face  becomes 
pale  and  his  limbs  cold ;  his  pulse  is  feeble  and  very 
rapid  ;  his  respirations  short  and  very  frequent ;  he 
often  sweats  profusely,  sometimes  vomits,  and  occa- 
sionally has  flatulence.  These  latter  accompaniments 
seem  to  point  to  a  neurosis  of  the  vagus,  while  the 
pallor  and  coldness  point  to  an  imperfect  filling  of  the 
left  ventricle.  The  dyspncea  I  believe  to  depend 
upon  a  failure  of  the  right  ventricle,  accompanied  in 
many  cases  if  not  always  by  an  acute  dilatation.     In 


such  attacks  my  house-physicians  have  often  suc- 
ceeded in  demonstrating  a  marked  increase  of  the 
cardiac  dullness  to  the  right  of  the  sternum,  and  on 
two  or  three  occasions  I  have  been  fortunate  enough 
to  be  present  when  an  attack  came  on,  and  to  be  able 
to  satisfy  myself  of  the  fact.  The  increase  in  trans- 
verse dullness  may  amount  to  as  much  as  two  finger- 
breadths,  and  I  have  found  it  returjt  to  the  normal 
when  the  attack  subsided.  I  have  also  observed  a 
temporary  tricuspid  systolic  murmur,  which  dis- 
appeared when  the  attack  was  over.  It  is  not,  how- 
ever, always  possible  to  demonstrate  this  dilatation, 
perhaps  because  it  is  often  masked  by  distension  of 
the  lung.  A  bdy  under  my  care  in  1891,  who  had 
many  attacks  of  this  kind,  in  several  of  which  the  acute 
dilatation  was  clearly  proved,  died  in  a  severe  attack 
in  which  the  house-physician  could  find  no  increase  of 
the  dullness.  At  the  necropsy  the  lungs  were  found 
extremely  insufflated  :  they  did  not  collapse  on  open- 
ing the  chest.  The  right  side  of  the  heart  was  dilated 
and  distended  with  blood.  The  mitral  valve  barely 
admitted  the  tip  of  my  little  finger.  Whenever  the 
right  ventricle  is  acutely  distended,  dyspnoea  is  at  once 
produced.  This  is  seen  in  its  most  acute  form  in  em- 
bolism of  the  pulmonary  artery,  and  in  the  only  case 
of  this  affection  which  I  have  had  under  treatment,  a 
prompt  venesection  saved  the  patient's  life.  In  less 
acute,  but  still  well-marked  degree,  it  may  be  seen  at 
the  onset  of  pericarditis,  which  rapidly  produces  dilata- 


176  SPASMODIC  DYSPNCEA  IN  MITRAL  STENOSIS 

tion.  This  dyspnoea  is,  I  believe,  not  merely  a  result 
of  stimulation  of  the  respiratory  centre  by  hypervenous 
blood,  but  a  true  physiological  reflex  similar  to  the 
action  exerted  by  stimulation  of  the  "  depressor  "  nerve 
on  the  vaso-motor  centre.  Just  as  the  result  of  the 
latter  is  to  open  up  the  vaso-motor  channels,  and  so  to 
relieve  the  left  ventricle,  and  prevent  its  paralysis  from 
over-distension,  so  I  believe  a  distension  of  the  right 
ventricle  tends  to  bring  about  its  own  relief  by  a  reflex 
stimulus  of  the  respiratory  centre. 

The  symptoms  pointing  to  vagus  disturbance  sug- 
gested to  me  the  employment  of  atropine,  which  has 
such  a  marked  physiological  action  on  this  nerve,  and  I 
have  found  it  of  very  great  service.  It  must,  however, 
be  given  in  sufficient  quantity.  Two  minims  of  the 
official  liquor  atropinae  sulphatis  ( =  -^  grain)  will 
usually  produce  little  effect,  but  a  hypodermic  injection 
of  4  minims  (=  J-  grain)  will  often  at  once  cut  short 
the  attack.  It  has  just  now  done  so  in  the  case  of 
this  girl.  She  was  seized  with  an  attack  while  we 
were  investigating  the  case  of  general  paralysis,  and 
Mr  Beggs  promptly  injected  4  minims  of  the  solu- 
tion. This  was  about  a  quarter  of  an  hour  ago,  and 
you  see  that  the  patient  is  now  free  from  distress, 
lying  comfortably  on  her  back,  breathing  fairly  easily, 
and  she  states  that  the  pain  has  nearly  disappeared. 
Nitrite  of  amyl  and  nitroglycerine  give  some  relief 
at  times,  but  they  are  far  inferior  to  atropine.  In 
two  or  three  instances  where   this    drug   has   failed, 


RELIEF  WY  ATROPINE  177 

j^rompt  relief  has  been  given  by  venesection.  Leeches 
also  and  dry  cupping  have  occasionally  been  useful. 
Hypodermic  strychnine  and  morphine  are  also  of 
service. 

Case  IV. — Cardiac  Dilatation.  Dropsy.  Action  of 
Digitalis. — This  patient,  a  middle-aged  woman,  came 
into  the  hospital  six  months  ago  with  cedema  of  both 
legs,  and  ascites.  The  area  of  cardiac  dullness  ex- 
tended almost  to  the  mid-axillary  line.  There  was 
mitral  and  tricuspid  incompetence,  which  passed  off,  so 
we  may  assume  that  it  did  not  depend  upon  valvular 
disease.  Under  digitalis  in  large  doses  she  improved 
very  rapidly,  and  she  was  soon  able  to  go  out  and 
follow  her  ordinary  occupation.  She  returned  here  a 
month  ago,  with  cedema  of  both  legs,  very  marked 
ascites,  and  gi'cat  increase  of  the  cardiac  dullness, 
especially  to  the  left.  The  abdomen  measured  48 
inches  in  circumference,  the  face  was  cyanosed,  and  it 
was  necessary  to  give  immediate  relief  One  and  a 
half  pints  of  fluid  were  therefore  drawn  off  from  the 
abdomen  by  means  of  Southey's  tubes.  Ten  minims 
of  the  tincture  of  digitalis  were  given  every  four 
hours,  and  a  remarkable  diuresis  ensued,  the  amount 
of  urine  on  four  successive  days  being  74,  144,  184, 
and  146  ounces.  The  digitalis  was  stopped,  and 
next  day  the  amount  of  urine  sank  to  52  oz.  and 
on  the  day  following  to  44  oz.  As  the  ascites 
diminished,  the  liver  was  found  to  be  enlarged,  firm, 
and  tender  to  the  touch.  It  was  also  discovered  that 
there  was  fluid  in  the  left  pleural  cavity;  16  oz. 
were  withdrawn  by  aspiration,  giving  further  relief 
to  the  breathing.  The  area  of  cardiac  dullness 
extends  nearly  to  the  anterior  axillary  line,  but  the 
impulse  is  distinct,  and  there  is  no  murmur  at  apex 
or  base. 

M 


178  CARDIAC  DILATATION 

What  is  the  cause  of  the  cardiac  dilatation  in  this 
case?  We  know  that  this  condition,  apart  from 
valvular  lesions,  may  be  due  to  pericarditis,  to  disease 
of  the  cardiac  walls,  permitting  of  their  giving  way 
before  a  normal  tension,  or  to  normal  cardiac  walls 
giving  way  before  excessive  tension,  especially  after 
sudden  exertion. 

There  is  nothing  in  this  case  which  would  make  us 
attribute  the  dilatation  to  the  effects  of  pericarditis. 
At  first  sight  there  appears  to  be  no  increase  of 
arterial  tension,  for  the  pulse  is  easily  compressible. 
But  when  we  listen  to  the  aortic  second  sound  we 
find  that  it  is  distinctly  a  little  too  loud,  and  that  to 
the  left  of  the  cardiac  apex  the  second  sound  "is 
undoubtedly  louder  than  normal.  These  facts  seem 
to  indicate  increase  of  arterial  tension,  in  spite  of  the 
compressibility  of  the  pulse.  And  we  must  remember 
that  there  are  two  factors  concerned  in  arterial  tension, 
the  resistance  in  the  arterioles  and  capillaries  in  front, 
and  the  force  of  the  left  ventricle  behind.  When 
prolonged  high  tension  has  damaged  the  heart  to  a 
certain  degree,  this  organ  can  no  longer  do  its  share 
in  keeping  up  the  pressure  in  the  arteries,  and  there 
is,  consequently,  a  fall  in  tension  recognisable  in  the 
pulse.  Thus  a  low-tension  pulse  may  mean  failing 
heart.  We  come,  therefore,  to  the  question  of  the 
cause  of  the  increase  of  tension  in  this  case.  The 
urine  is  of  low  specific  gravity,  contains  no  urates,  a 
trace  of  albumen,  but  no  casts.     This  strongly  suggests 


CAUSATION  AND  TREATMENT  179 

the  presence  of  granular  kidneys,  the  common  cause 
of  increased  arterial  tension.  Were  the  albuminuria 
due  to  the  heart  condition,  we  should  expect  the  urine 
to  be  of  high  specific  gravity  and  to  contain  abun- 
dance of  urates. 

It  is  probably,  therefore,  primarily  a  case  of  granular 
kidney  in  which  the  left  ventricle  has  yielded  to  the 
pressure  ;  and  it  is  quite  likely  that  -the  ventricle-wall 
itself  has  undergone  a  fibroid  degeneration. 

The  enlargement  of  the  liver  is  probably  due  to 
passive  congestion  owing  to  back-pressure,  on  which 
a  secondary  cirrhosis,  an  increase  of  fibroid  tissue, 
has  supervened,  and  there  may  be  some  perihepatitis. 
Of  course  there'  may  have  been  a  primary  cirrhosis, 
but  we  have  no  reason  to  suspect  the  patient  of 
alcoholic  habits. 

The  pleural  effusion  is  doubtless  simply  a  dropsy. 
It  is  remarkable  that  hydrothorax,  which  one  would 
think  ought  to  be  a  symmetrical  condition,  alike  on 
the  two  sides  of  the  body,  is  frequently  unilateral,  as 
it  is  in  this  case.     The  cause  of  this  is  not  evident. 

From  the  point  of  view  of  treatment  this  case  is 
interesting.  It  shows  the  marked  relief  obtained  by 
drawing  off  fluid  from  the  abdomen,  and  again  from 
the  pleura.  It  illustrates  also  very  remarkably  the 
beneficial  action  of  digitalis  in  suitable  cases.  The 
very  copious  diuresis  which  resulted  from  it,  and 
which  ceased  when  it  was  discontinued,  is  proof  of 
this.     Such  diuresis  is  brought  about  by  an  increase 


180  CARDIAC  DILATATION 

in  the  arterial  tension  which  digitalis  effects.  This 
increase  is  partly  due  to  the  action  of  the  drug  on 
the  vaso-motor  centre,  partly  to  its  effect  on  the 
muscular  fibre  of  the  heart  and  the  arterioles.  It 
is  impossible  to  explain  its  action  entirely  by  its 
influence  on  cardiac  muscle,  for  physiologists  find 
that  in  warm-blooded  animals  it  does  not  raise 
arterial  tension  when  the  spinal  cord  is  severed  in 
the  neck,  and  does  not  slow  the  action  of  the  heart 
after  section  of  the  vagi.  Hence,  in  warm-blooded 
animals  it  must  act  mainly  through  the  nervous 
system,  and  clinically  it  is  found  often  to  be  useless 
for  hearts  that  are  merely  weak,  and  helpful  to  many 
hearts  that  are  considerably  hypertrophied  if  dilatation 
be  also  present.  Nor  is  it  mere  rapidity  of  action 
that  digitalis  influences,  for  in  neurotic  tachycardia 
it  is  useless.  But  the  rapid,  irregular  heart,  with 
dilated  left  ventricle  and  low  arterial  tension,  is  always 
benefited  by  it. 


IS   THERE  A   DEXTROCARDIAC- 
RESPIRATORY  REFLEX? 

{Lancet^  28th  October  1893.) 

The  object  of  this  paper  is  to  suggest  for  the  con- 
sideration of  physiologists  the  question  whether  there 
is  not  a  physiological  reflex  from  the  right  ventricle 
of  the  heart  to  the  respiratory  centre,  similar  to  that 
from  the  left  ventricle  along  the  depressor  nerves  to 
the  vaso-motor  centre,  and  with  a  similar  function — 
viz.,  the  automatic  relief  of  over-distension  of  the 
ventricle.  The  suggestion  is  founded  on  the  follow- 
ing observations  of  clinical  phenomena. 

( I )   The  Dysp7icEa  of  Pericarditis, 

I    have   lately  had  under  my  care  at  St  Mary's 

Hospital  a  youth  of  17  years  of  age,  suffering  from  a 

first  attack  of  rheumatism.     He  had  felt  rheumatic 

pains  for  about  a  fortnight  before  admission,  but  had 

been  really  ill  for  only  five  days.     On  examination, 

he  was  found  to  have  rheumatic  swelling  of  the  wrist, 

and   commencing   pericarditis.      Distinct   pericardial 
isi 


182    DEXTROCARDIAC-RESPIRATORY  REFLEX 

friction-sounds  could  be  heard  over  nearly  the  whole 
surface  of  the  heart,  especially  at  the  base  and 
apex,  and  the  absolute  cardiac  dullness  was  in- 
creased, for  it  extended  from  the  right  border  of 
the  sternum  to  half  a  fingerbreadth  outside  the  left 
nipple-line.  There  was  only  the  smallest  possible 
patch  of  pleurisy ;  there  was  no  pneumonia  and  no 
valvular  murmur,  yet  the  number  of  respirations  was 
36  in  the  minute,  the  pulse  being  only  100,  and  the 
temperature  102.5"  F.  On  inspection,  the  respiratory 
excursions  of  the  thorax  were  seen  to  be  markedly 
greater  than  normal.  This  was  not  due  to  any  paresis 
of  the  diaphragm  caused  by  the  pericarditis,  for  the 
epigastrium  became  prominent  during  each  inspira- 
tion, and  the  diaphragm  was  acting  quite  normally. 
Nor  is  this  all  ;  the  sterno-mastoids  were  working, 
and  even  the  nostrils  were  dilating.  Clearly  the 
respiratory  centre  was  stimulated  to  increased  action. 
What  is  the  explanation  of  this  phenomenon  ?  There 
was  no  obstacle  to  the  flow  of  blood  through  the  lungs 
or  hindrance  to  the  access  of  air ;  there  was  no 
valvular  disease  of  the  heart — in  short,  there  was 
nothing  but  the  pericarditis.  The  pericardial  inflam- 
mation had  produced  dilatation  of  both  sides  of  the 
heart,  as  was  evidenced  by  the  increased  percussion 
dullness,  and  the  muscular  structure  of  each  ventricle 
was  no  doubt  rendered  less  efficient.  The  failure  of 
the  left  ventricle  showed  itself  in  the  softness  and 
shortness  of  the   pulse  ;    that  of  the   right  ventricle 


THE  DYSPNCEA  OF  PERICARDITIS  183 

produced,  I  would  venture  to  suggest,  the  dyspncca. 
But  how  ?  Not,  I  think,  by  the  medium  of  cyanosis. 
The  boy's  face  and  lips  were  not  dusky  ;  he  had  been 
ill  for  only  a  few  days ;  and  considering  the  absence 
of  any  disease  of  the  lungs,  it  is  probable  that  there 
was  very  little  defect  in  the  aeration  of  his  blood. 
How  then  was  his  very  obvious  dyspnoea  produced  ? 
I  would  suggest  that  it  was  due*  -to  the  working  of 
an  automatic  reflex  from  the  right  ventricle  to  the 
respiratory  centre,  called  into  action  by  the  acute 
failure  of  the  right  ventricle  resulting  from  the  peri- 
carditis or  by  irritation  of  the  subpericardial  nerves. 
The  same  phenomenon — an  early  and  acute  dyspnoea 
— occurs  ordinarily  in  cases  of  pericarditis ;  but  no 
explanation  of  it,  as  far  as  I  am  aware,  has  been  given. 
It  is  sometimes  very  marked,  occasionally  even  caus- 
ing orthopnoea  ;  but  this  case  presents  the  question 
in  an  unusually  uncomplicated  manner,  for  there  was 
no  affection  of  the  lungs  and  almost  none  of  the 
pleura,  and  no  previous  or  present  valvular  disease. 
The  dyspnoea  was  the  result  of  the  pericarditis  and 
of  nothing  else. 

(2)    TJie  sudden  and  agonising  Dyspncea  of  P2ilni07iary 
Embolism. 

Three  years  ago  a  young  man,  23  years  of  age,  who 
was  under  my  care  at  St  Mary's  Hospital  for  pleuritic 
effusion  on  the  left  side,  while  using  the  bedpan  (the 
nurse  standing  by  his  bedside)  was  suddenly  seized 


184    DEXTROCARDIAC-RESPIRATORY  REFLEX 

with  great  dyspncea,  became  cyanosed,  and  called  out 
"  Give  me  air,  give  me  air !  "  The  house-physician 
was  at  once  summoned,  and  found  the  patient /«/^,  so 
that  he  feared  internal  haemorrhage  had  occurred. 
He  at  once  aspirated  the  left  pleura,  removing  40  ozs. 
of  serous  fluid,  and  injected  strychnine  and  digitalis 
subcutaneously.  Finally,  the  patient  was  wet-cupped 
over  the  back  to  4  ozs. ;  this  seemed  to  give  some 
relief  I  saw  the  patient  four  hours  after  the  seizure  ; 
he  was  then  sitting  up  in  bed,  his  face  was  ashy-livid, 
and  his  breathing  sighing  (32) ;  his  pulse  was  com- 
pressible (140).  Deep  inspirations  could  now  be 
heard  all  over  both  lungs,  though  mingled  with 
pleuritic  rub-crackles  on  the  left  side.  The  cardiac 
impulse  was  felt  over  a  much  larger  area  than  before, 
it  was  very  forcible  in  the  epigastrium,  and  was 
distinctly  felt  to  the  right  of  the  sternum.  Fortun- 
ately I  had  examined  his  heart  on  the  previous  day, 
and  had  specially  noted  that  the  cardiac  impulse 
could  not  then  be  felt  to  the  right  of  the  sternum, 
although  the  left  pleura  was  full  of  fluid.  Yet  now, 
though  the  fluid  had  been  withdrawn,  the  impulse  was 
easily  felt  to  the  right  of  the  sternum,  and  it  was  much 
more  violent  in  the  epigastrium  than  previously.  It 
was  clear  that  the  right  side  of  the  heart  was  dis- 
tended and  acting  strongly.  There  was  no  murmur. 
Venesection  to  6  ozs.  was  at  once  performed ;  after 
this  he  felt  easier,  and  there  was  decidedly  less 
violent  pulsation.     The  next  day  he  was  much  less 


DYSPNCEA  OF  PULMONARY  EMBOLISM    185 

distressed,  though  the  nostrils  were  still  dilating  and 
the  breathing  was  somewhat  gasping ;  the  heart's 
impulse  could  not  be  felt  at  all  to  the  right  of  the 
sternum.  On  the  following  day  he  was  decidedly 
better ;  the  cardiac  impulse  could  not  be  felt  any- 
where. There  were  still  rather  marked  expansion  of 
the  chest,  descent  of  the  diaphragm,  and  dilatation  of 
the  nostrils.  A  loud,  rough,  pleuritic  rub  could  be 
heard  all  over  the  left  side,  and  good  entry  of  air 
everywhere.  He  left  the  hospital  convalescent ;  but 
a  year  later  he  was  re-admitted,  dying  from  acute 
tuberculosis. 

It  cannot  be  doubted,  I  think,  that  the  cause  of  this 
patient's  agonising  distress  was  the  occurrence  of  a 
pulmonary  embolism.  The  sudden  check  to  the 
aeration  of  the  blood  caused  the  cyanosis,  which  at 
once  became  manifest,  and  the  impeded  supply  of 
blood  to  the  left  ventricle  produced  the  pallor  which, 
combined  with  the  cyanosis,  caused  the  peculiar  ashy- 
livid  tint  of  his  complexion  when  I  saw  him.  Possibly 
the  cyanosis  may  be  the  explanation  of  the  intense 
dyspnoea  which  was  at  once  manifested,  but  I  was 
much  struck  with  the  evidence  of  an  acute  dilatation 
of  the  right  ventricle,  and  with  the  relief  that  was 
afforded  by  venesection.  The  withdrawal  of  blood 
produced  marked  diminution  of  the  dyspnoea,  and  also 
of  the  physical  signs  of  cardiac  dilatation,  and  both 
improved  pari  passu  during  the  next  two  days.  Now 
the  removal  of  blood  could  not  influence  the  clot  in 


186    DEXTROCARDIAC-RESPIRATORY  REFLEX 

the  pulmonary  artery ;  it  could  only  relieve  the 
extreme  pressure  which  the  obstacle  to  the  pulmonary 
circulation  had  caused  in  the  right  ventricle.  Hence 
it  seems  to  me  probable  that  the  dyspnoea  was 
dependent,  not  simply  on  the  cyanosis,  but  also  on 
the  overstrain  on  the  right  ventricle,  and  that  even 
the  intense  dyspnoea  of  the  sudden  onset  was  due  to 
an  acute  dilatation  of  the  ventricle  quite  as  much  as 
to  the  rapid  cyanosis.  It  seems  to  suggest  that  the 
ereat  strain  at  once  thrown  on  the  ventricle  stimu- 
lated  intensely  a  normal  reflex  to  the  respiratory 
centre. 

(3)   The  Paroxysmal  Dyspnoea  of  Mitral  Stenosis. 

In  some  cases  of  mitral  stenosis,  quite  apart  from 
the  chronic  shortness  of  breath,  bronchitis,  pulmonary 
congestions,  haemorrhages,  and  infarcts,  there  occur 
from  time  to  time  paroxysmal  attacks  of  dyspnoea, 
lasting  usually  for  several  hours  if  not  cut  short  by 
treatment.  These  attacks  begin  with  increasing 
difficulty  of  breathing,  but  not  suddenly,  and  there  is 
often  a  sense  of  oppression  at  the  chest  which  may 
finally  become  distinct  precordial  pain.  The  number 
of  respirations  rapidly  increases  to  30,  40,  50,  or  even 
60  per  minute,  the  frequency  of  the  pulse  rising  to 
120,  150,  or  even  200.  The  patient  is  in  great 
distress,  and  is  usually  very  pale,  often  sweating  pro- 
fusely ;  not  infrequently  there  is  vomiting  during  the 
attack,  occasionally  flatulence,  and  sometimes  coldness 


PAROXYSMAL  DYSPNCEA  187 

of  the  limbs.  Careful  percussion  of  the  heart  during 
such  an  attack  will  often  give  clear  proof  of  the 
presence  of  temporary  dilatation  of  the  right  side.  I 
have  myself  verified  this  on  several  occasions.  Two 
methods  of  treatment  will  often  cut  short  such 
attacks  :  one  is  the  withdrawal  of  blood  by  leeches  or 
venesection  ;  the  other  is  the  subcutaneous  injection 
of  the  thirtieth  or  twenty-fifth  of  a -grain  of  atropine. 
I  have  several  times  seen  an  attack  arrested  in  ten  or 
fifteen  minutes  by  such  an  injection.  As  an  illustra- 
tion I  may  quote  the  case  of  a  boy  of  i6  years  of  age, 
who  was  under  my  care  at  St  Mary's  Hospital  for 
several  months  during  the  years  1890-91-92,  whose 
mitral  orifice  at  the  necropsy  barely  admitted  the  tip 
of  my  little  finger.  He  had  many  attacks  of  dyspnoea 
of  the  kind  above  described,  and  on  several  occasions 
was  rapidly  relieved  by  atropine  -  injections.  On 
30th  December  1891,  I  witnessed  an  attack.  The 
boy  was  sitting  upright  in  bed,  his  face  very  pale  and 
covered  with  a  cold  sweat,  taking  rapid,  deep  inspira- 
tions, and  looking  like  a  person  thoroughly  exhausted 
from  running.  The  number  of  inspirations  in  the 
minute  was  48,  the  pulse-rate  140.  The  cardiac 
dullness  extended  from  two  fingerbreadths  to  the 
right  of  the  right  margin  of  the  sternum  to  one 
fingerbreadth  to  the  left  of  the  left  nipple-line ; 
his  presystolic  murmur  had  vanished,  and  was 
replaced  by  a  short  tricuspid  systolic  murmur.  Three 
minims    of    liquor    atropinae    (B.P.)    were    injected. 


188    DEXTROCARDIAC-RESPIRATORY  REFLEX 

Eight  minutes  later  his  breathing  was  not  deeper 
than  normal,  though  still  48  in  the  minute,  and  the 
pulse  was  still  140.  A  few  hours  later  it  was  found 
that  the  limit  of  absolute  dullness  on  the  right  had 
receded  to  the  mid-sternum.  The  following  day  I 
saw  him  again,  and  noted  that  the  respirations 
numbered  only  28  and  the  pulse  90.  I  found  that 
the  absolute  cardiac  dullness  did  not  pass  to  the 
right  of  the  mid-sternum.  The  tricuspid  murmur 
had  vanished,  and  the  presystolic  mitral  had  re- 
turned. He  died  in  a  dyspnoeal  attack  of  this  kind, 
and  his  lungs  post-mortem  were  found  to  be  ex- 
tremely insufflated,  not  collapsing  when  removed, 
but  showing  no  consolidation.  The  mitral  orifice 
admitted  only  the  tip  of  the  little  finger ;  the  left 
ventricle  was  small ;  the  right  ventricle  was  dilated, 
forming  the  entire  front  of  the  heart,  and  hyper- 
trophied,  its  muscular  wall  measuring  three-tenths  of 
an  inch  in  thickness — precisely  the  same  thickness  as 
the  wall  of  the  left  ventricle. 

In  attacks  of  this  kind  it  is  not  always  possible  to 
demonstrate  clinically  the  temporary  dilatation  of  the 
right  side  of  the  heart,  but  often  it  is  unmistakable, 
and  the  fact  seems  to  throw  a  light  on  the  causation 
of  this  paroxysmal  dyspnoea.  It  seems  to  indicate 
an  acute  failure  of  the  right  ventricle  to  overcome  the 
high  tension  in  the  pulmonary  circuit,  and  to  be 
analogous  to  the  angina  which  sometimes  is  the 
result   of  an    acute    failure    of   the    left   ventricle   to 


CARDIAC  DYSPNCEA  IN  GENERAL         189 

overcome  increased  tension  in  the  aorta.  If  the 
dilatation  of  the  right  heart  does  produce  this  peculiar 
dyspnoea,  in  what  way  is  the  effect  brought  about  ? 
There  is  no  great  degree  of  cyanosis,  yet  the  respira- 
tory centre  is  acting  strongly,  for  the  inspirations  are 
both  rapid  and  deep.  The  vomiting  which  not 
seldom  accompanies  such  attacks,  the  relief  afforded 
by  atropine,  and  the  fact  that  occasionally  an  attack 
appears  to  be  brought  on  by  fright,  seem  to  indicate 
that  there  is  a  neurotic  element  in  their  causation. 
But  that  does  not  consist  in  a  spasm  of  the 
bronchioles,  for  during  the  paroxysm  there  is  not  the 
general  wheezing  of  an  attack  of  asthma.  The  pheno- 
mena appear  to  me  to  afford  support  to  the  hypothesis 
that  there  is  a  nervous  reflex  from  the  right  ventricle 
to  the  respiratory  centre,  and  that  when  the  ventricle 
fails,  excitement  of  this  reflex  causes  dyspncea. 

(4)  Cardiac  Dyspnoea  in  general. 

What  is  the  causation  of  ordinary  cardiac  dyspnoea  ? 
It  is  characterised  by  a  sort  of  air-hunger,  and  cannot 
be  accounted  for  simply  by  the  physical  changes  in 
the  lungs  which  may  result  from  cardiac  disease.  It 
is  often  much  more  severe  than  such  resulting 
changes  would  account  for,  and  it  may  exist  when  no 
such  changes  can  be  demonstrated.  The  check  to 
the  pulmonary  circulation  no  doubt  causes  a  defici- 
ency in  the  aeration  of  the  blood,  but  not  for  a  long 
time  sufficient  cyanosis  to  account  for  the  dyspnoea. 


190    DEXTROCARDIAC-RESPIRATORY  REFLEX 

It  is  well  recognised  that  in  cases  of  mitral  disease, 
the  effectiveness  of  compensation  depends  on  the 
vigour  of  action  of  the  right  ventricle.  When  there 
is  marked  epigastric  pulsation,  compensation  may  be 
effectual  in  mitral  disease,  and  there  ma}'  be  no 
dyspnoea ;  but  if  the  right  ventricle  fails,  dyspnoea  is 
at  once  observed.  Is  this  through  non-aeration  of 
blood  ?  Is  it  not  more  probably  through  excitation 
of  a  normal  i-eflex  to  the  respiratory  centre  ? 

(5)  Dyspncea  of  Muscular  Exertion. 

Is  not  this  due  to  the  arrival  of  venous  blood  in  the 
right  side  of  the  heart  more  rapidly  than  the  ventricle 
is  competent  to  pass  it  on  into  the  lungs?  Hence 
the  tension  in  the  right  ventricle  rises,  the  muscular 
walls  tend  to  dilate,  and  a  stimulus  probably  ascends 
to  the  respiratory  centre,  whereby  more  rapid  and 
deeper  inspirations  expand  the  pulmonary  channels, 
and  so  relieve  the  labouring  ventricle.  Is  not  the 
management  of  the  breath,  which  is  the  main  part  of 
the  training  for  athletic  exercises,  simply  an  education 
of  the  right  ventricle  ? 

As  to  the  path  of  this  hypothetical  reflex,  it  may 
be  suggested  that  its  afferent  part  is  through  the 
superficial  or  the  deep  cardiac  plexus  into  the  vagus. 
Possibly  an  irritation  of  this  reflex  through  pressure 
on  these  plexuses  may  be  the  explanation  of  the 
paroxysmal  dyspnoea  observed  in  some  cases  of 
aortic   aneurism,   which    also,  as   I   have   seen,    may 


DYSPNCEA  OF  MUSCULAR  EXERTION      191 

sometimes  be  almost  immediately  arrested  by  sub- 
cutaneous injections  of  atropine. 

It  seems  to  me  also  probable  that  a  stimulating 
reflex  exists  from  the  right  ventricle  to  the  vaso-nwtor 
centre^  which  manifests  itself  in  the  increased  arterial 
tension  observed  in  mitral  stenosis  and  in  emphysema, 
but  which  is  masked  in  the  dilatation  of  the  right 
ventricle,  resulting  from  mitral  regurgitation  by  the 
depressing  influence  on  the  vaso-motor  centre  exerted 
by  the  dilated  left  ventricle.  Such  a  stimulating  reflex 
from  the  right  ventricle  to  the  vaso-motor  centre  would 
increase  the  tension  in  the  coronary  arteries  and  thus 
promote  the  nutrition,  and  therefore  the  strength  of 
contraction,  of  the  right  ventricle,  in  the  same  way  as 
was  observed  by  Professors  Roy  and  Adami  after 
narrowing  the  aorta. 


ACUTE  DILATATION    OF   THE    HEART  IN 
RHEUMATIC  FEVER. 

{Medico-Chirurgical  Tra7isactions^  1898.) 

It  is  not,  I  think,  sufficiently  recognised  that  acute 
dilatation  of  the  heart  is  a  frequent,  almost  a  constant, 
occurrence  in  a  rheumatic  attack.  Attention  has 
been  too  exclusively  directed  to  the  auscultatory 
phenomena  as  indicative  of  the  presence  of  pericar- 
ditis or  endocarditis,  and  it  seems  to  have  escaped 
notice  that  whether  either  or  both  of  these  inflamma- 
tory conditions  be  present,  or  whether  both  be  absent, 
there  is  almost  always  in  rheumatic  fever  more  or 
less  dilatation  of  the  heart.  As  a  part  of  the  chronic 
cardiac  disease  caused  by  rheumatism,  dilatation  is 
generally  acknowledged  to  be  of  great  importance, 
but  it  is  too  much  regarded  as  merely  one  of  the 
results  of  a  valve-lesion  or  possibly  of  an  adherent 
pericardium. 

In  studying  the  curative  influence  of  the  icebag  in 
pericarditis,  I  found  it  necessary  to  determine  caie- 

192 


FIRST  OBSERVATIONS  193 

fully  day  by  day  the  limits  of  the  precordial  dullness, 
and  I  was  struck  with  the  evidence  of  a  rapid  and 
often  permanent  dilatation  of  the  heart  accompanying 
the  signs  of  pericarditis.  In  a  paper  on  the  "  Treat- 
ment of  Pericarditis,"  published  in  the  Lancet^  22nd 
July  1893,  I  attributed  this  early  dilatation  to  the 
weakening  effect  of  the  pericardial  inflammation  on 
the  cardiac  muscular  wall. 

But  observation  of  the  fact  that  cardiac  dilatation 
is  much  less  marked  in  pericarditis  of  renal  origin,  or 
of  tubercular  or  suppurative  nature,  suggested  a 
doubt  whether  this  explanation  of  the  dilatation 
accompanying  rheumatic  pericarditis  was  altogether 
adequate,  and  the  subsequent  discovery  of  cases  of 
rheumatism  in  which  marked  dilatation  of  the  heart 
was  present  without  any  evidence  of  either  pericar- 
ditis or  endocarditis,  proved  that  there  must  be  some 
other  influence  at  work. 

In  December  1894,  I  had  under  my  care  in  St 
Mary's  Hospital  a  young  man  of  seventeen,  suffering 
from  his  first  attack  of  rheumatism,  in  whom  the 
precordial  dullness  was  greatly  enlarged,  without  any 
definite  murmur  and  without  any  friction  or  other 
indication  of  pericarditis.  I  am  aware  that  an 
audible  rub  is  not  invariably  present  in  pericarditis, 
but  the  cases  in  which  I  have  observed  this  have  been 
of  suppurative  nature,  and  I  doubt  whether  this  com- 
plete absence  of  rub  throughout  the  case  ever  occurs 
in  rheumatic  pericarditis.     That  the  increase  of  the 

N 


194      ACUTE  DILATATION  OF  THE  HEART 

precordial  dullness  was  not  due  to  effusion  into  the 
pericardium,  seemed  to  be  proved  by  the  palpable 
cardiac  impulse,  the  distinctly  audible  heart-sounds, 
and  the  absence  of  dyspnoea  and  distress.  Under 
treatment,  this  increase  in  the  dullness  gradually 
became  less,  and  returned  to  the  normal.  In  1896 
I  had  three  similar  cases ;  in  these  I  took  trac- 
ings of  the  enlarged  area  of  dullness,  and  again 
found  that  it  diminished  under  treatment  and  gradu- 
ally returned  to  the  normal.  One  of  these  patients 
had  been  in  the  hospital  under  my  care  four  months 
before  (1895)  with  a  previous  attack  of  rheumatism, 
attended  with  great  increase  of  the  precordial  dull- 
ness without  either  rub  or  murmur,  and  on  this  occa- 
sion also  the  excess  in  the  dullness  had  disappeared 
on  his  recovery. 

Before  showing  these  tracings  as  evidence  of  altera- 
tion in  the  outline  of  the  heart,  one  must  decide 
whether  percussion  is  trustworthy  as  a  means  of 
determining  with  accuracy  the  size  of  the  heart.  If 
an  opinion  on  this  matter  had  to  be  formed  from  the 
statements  in  textbooks,  this  would  seem  extremely 
doubtful ;  but  the  valuable  papers  of  Dr  Ewart  in  the 
Lancet  of  29th  August  1891,  and  the  British  Medical 
Journal  of  2  ist  March  1896,  show  that  the  true  outline 
of  the  heart  can  be  much  more  precisely  ascertained 
than  most  physicians  have  supposed,  while  the  paper 
read  by  Dr  Herringham  before  the  British  Medical 
Association  at  Carlisle  in  July  1896,  proves  that  the 


PHYSICAL  INVESTIGATION  195 

results  thus  obtained  are  almost  exactly  verified  by- 
post-mortem  examination. 

Confusion  is  introduced  into  this  question  by  the 
terms  "  superficial "  and  "  deep."  What  is  called 
"  superficial  cardiac  dullness  "  is  of  no  cardiac  value 
whatever.  It  is  of  importance  as  indicating  the  con- 
dition of  the  left  lung,  whether  on  the  one  hand  it  is 
emphysematous,  or  on  the  other  shruTTken  and  fibrosed. 
But  it  would  be  much  better  to  speak  of  the  "  un- 
covered cardiac  area."  The  term  "  cardiac  dullness  " 
would  then  be  understood  to  indicate  the  real  size  of 
the  heart,  a  fact  of  the  greatest  importance. 

In  this  way  we  should  get  rid  also  of  the  term 
"  deep,"  which  is  apt  to  suggest  that  the  percussion 
required  to  determine  the  true  cardiac  outline  must 
be  of  a  forcible  kind.  This  is  the  very  reverse  of  the 
truth,  for  such  percussion  brings  out  the  pulmonary 
and  gastric  resonances  and  defeats  its  own  object. 
Light  percussion  is  absolutely  necessary,  especially 
over  the  sternum,  which  very  readily  conducts  reson- 
ance from  the  lungs.  If  this  be  constantly  kept  in 
mind,  there  is  usually  little  difficulty  in  defining 
with  very  considerable  accuracy  the  outline  of  the 
heart  on  both  left  and  right  sides,  for  the  cardiac 
margin  on  both  sides  is  comparatively  thick,  and  the 
alteration  of  the  note  on  light  percussion  at  the 
margin  is  generally  quite  definite. 

It  is  well  to  begin  in  the  region  of  the  apex,  and  to 
remember  that  the  left  limit  of  the  cardiac  dullness 


196      ACUTE  DILATATION  OF  THE  HEART 

extends  beyond,  in  dilatation  often  much  beyond,  the 
position  of  the  impulse.  The  precise  position  of  this 
limit  should  be  found  in  the  fourth  and  in  the  fifth 
spaces,  sometimes  in  the  sixth  also. 

Next,  the  extension  towards  the  right  of  the  right 
auricle  should  be  determined  by  very  careful  light 
percussion  to  the  right  of  the  sternum  in  the  fourth 
space,  just  below  the  line  joining  nipple  to  nipple.  In 
the  fifth  space  it  is  somewhat  more  difficult,  because 
the  partial  hepatic  dullness  is  here  present  also,  but  it 
can  usually  be  defined  satisfactorily.  In  health,  there 
is  always  about  one  fingerbreadth  of  dullness  to  the 
right  of  the  sternum  in  the  fourth  space,  in  accordance 
with  the  anatomical  facts.*  When  the  auricle  is 
dilated,  as  in  mitral  stenosis,  the  limit  may  be  two  or 
even  three  fingerbreadths  to  the  right  of  the  sternum. 
This  is  a  most  valuable  indication  of  the  condition  of 
the  right  auricle,  and  one  too  much  neglected ;  it  is 
often  of  great  assistance  in  determining  whether 
removal  of  blood,  by  venesection  or  by  leeches,  is 
desirable  in  mitral  disease  or  in  pneumonia. 

I  measure  by  fingerbreadths  rather  than  by  inches 
or  centimetres,  for  the  use  of  these  measures  would 
imply  that  the  limit  can  be  determined  with  mathe- 
matical precision,  which  is  not  the  case  ;  no  more 
than  a  close  approximation  can  be  claimed.  The 
measure    by    fingerbreadths    is     made    during    the 

*  See  also  the  "  radiographs  "  of  the  cardiac  outHne,  by  Dr 
Williams  of  Boston,  Brit.  Med.  Jour?i.,  1898,  vol.  i.,  p.  1006. 


MEASUREMENT  BY  FINGERBREADTHS    197 

routine  examination  by  percussion,  it  is  made  without 
any  marking  of  the  patient's  skin,  and  without 
exciting  his  attention  ;  it  is  a  measure  which  the 
physician  ahvays  carries  with  him,  and  it  is  invariable 
for  the  same  observer. 

Having  determined  the  extreme  cardiac  Hmit  both 
to  left  and  to  right,  the  position  of  the  lateral  margins 
of  the  heart  may  easily  be  defined  i^  i-t  be  remembered 
that  they  both  slope  upwards  and  inwards,  and  the 
percussed  finger  be  held  in  a  position  parallel  to  this 
slope  in  each  case.  The  right  margin  above  the 
nipple-level  rapidly  approaches  the  sternum.  The 
left  margin  normally  rises  to  the  inner  side  of  the 
nipple,  but  in  a  moderately  dilated  heart  the  limit  of 
dullness  will  be  found  to  pass  through  the  nipple,  and 
where  the  dilatation  is  great  it  may  cross  the  vertical 
nipple-line  at  one,  two,  in  extreme  cases  even  three, 
fingerbreadths  above  the  nipple.  A  little  practice 
gives  facility  in  determining  the  opposite  borders  of 
the  heart,  so  that  even  without  any  marking  of  the 
skin  one  seems  almost  to  see  the  outline  of  the  heart. 
But  a  permanent  record  can  easily  be  obtained  by 
marking  the  outline  with  a  blue  pencil  and  taking  a 
copy  of  this  on  tracing-paper,  care  being  taken  to 
indicate  in  all  cases  the  median  line,  the  infra-costal 
angle,  and  the  position  of  the  nipple,  as  points  of 
reference.  The  extension  of  the  cardiac  dullness  to 
left  and  to  right  of  the  median  line  may  then  be 
measured  in  inches  or  centimetres. 


198      ACUTE  DILATATION  OF  THE  HEART 

The  upper  and  lower  limits  of  the  cardiac  outline 
are  less  easy  to  determine  satisfactorily.  Dr  Ewart's 
observations  about  them,  in  the  papers  already 
referred  to,  will  repay  perusal.  I  have  usually  re- 
frained from  attempting  to  include  the  lower  limit  in 
the  tracings,  and  I  lay  no  stress  on  the  accuracy  or 
the  precise  meaning  of  the  upper  limit  of  the  dullness, 
for  the  sternum  and  the  great  vessels  here  cause 
difficulty. 

It  may  be  well  to  add  that  the  precise  determination 
of  the  limit  of  the  heart  to  right  or  to  left  may  be 
impossible  when  there  is  fluid  in  the  pleura,  and  it 
may  be  difficult  when  the  breasts  are  large,  when 
there  is  consolidation  of  parts  of  the  lungs  adjacent 
to  the  heart,  or  when  emphysema  exists.  Fortunately, 
emphysema  is  rarely  present  in  the  subjects  of  acute 
rheumatism,  who  are  usually  in  the  earlier  half  of 
life.  But  if  emphysema,  pleurisy,  and  consolidation 
of  lung  are  absent,  the  lateral  outline  of  the  heart 
obtained  by  careful  light  percussion  is  almost  absol- 
utely correct,  as  I  have  found  by  post-mortem  in- 
vestigation. If  the  outline  determined  by  percussion 
be  marked  on  the  cadaver,  and  long  needles  be  passed 
through  various  points  in  the  bounding  line  on  either 
side,  it  is  found  that  they  correspond  with  surprising 
accuracy  to  the  margin  of  the  heart. 

It  seems  to  me  very  important  that  a  determination 
of  its  exact  size  by  careful  light  percussion  should 
invariably  form  a  part  of  the  routine  examination  of 


CAREFUL  LIGHT  PERCUSSION  199 

the  heart.  For  it  is  dilatation  that  is  the  enemy,  and 
an  exact  knowledge  of  the  size  and  strength  of  the 
heart  is  far  more  important  than  the  most  elaborate 
and  minute  study  of  murmurs.  It  is  very  necessary 
in  typhoid  fever,  where  the  cardiac  condition  is  of 
great  importance ;  it  is  indispensable  in  influenza  and 
in  diphtheritic  paralysis,  in  both  of  which  sudden 
death  may  occur  from  syncope ;  it^  may  save  life  by 
indicating  the  need  for  blood-letting  when  the  right 
heart  is  becoming  paralysed  from  over-distension  in 
pneumonia,  capillary  bronchitis,  or  mitral  disease. 
And  surely  in  rheumatic  fever,  a  disease  known 
specially  to  injure  the  heart,  it  ought  never  to  be 
neglected.  Y^t  are  we  not  all  too  apt  to  use  our 
stethoscope  and  neglect  percussion,  forgetting  Sir 
George  Humphry's  rule,  "  Eyes  first,  fingers  next, 
ears  last"}  We  are  prone  to  be  satisfied  if  no 
murmur  is  audible.  Yet  in  the  absence  of  murmur 
there  may  be  great  dilatation  ;  in  proof  of  this  I  sub- 
mit the  following  tracings. 

The  first  three  sets  of  tracings  are  taken  from  the 
cases  of  three  young  men  suffering  from  their  first  or 
second  attack  of  rheumatism,  in  none  of  whom  any 
rub  or  definite  murmur  was  audible,  but  in  all  of 
whom  the  cardiac  dullness  was  for  a  time  considerably 
enlarged.  In  all  three  the  cardiac  dullness  extended 
one  and  a  half  or  two  fingerbreadths  to  the  left  of  the 
nipple-line,  and  one  or  one  and  a  half  fingerbreadths 
to  the  right  of  the  sternum,  on  their  admission  into 


200      ACUTE  DILATATION  OF  THE  HEART 

hospital ;  in  all  three  it  shrank  to  the  normal  dimen- 
sions as  the  rheumatic  symptoms  disappeared  under 
treatment.  I  now  show  three  tracings  in  each  case, 
the  first  taken  on  commencing  treatment,  the  third 
on  recovery,  and  the  second  at  an  intermediate  stage. 
Other  tracings  were  taken,  and  these  manifest  a 
gradual  reduction,  but  for  the  sake  of  clearness  I 
show  only  three  in  each  case.  Every  tracing  was 
taken  without  reference  to  previous  diagrams  of  the 
same  case,  so  as  to  eliminate  the  element  of  bias  as 
much  as  possible.  They  were  carefully  reduced  in 
size  on  the  same  scale  by  Dr  Poynton,  and  painted 
on  glass,  in  order  to  make  it  possible  to  throw 
them  on  a  screen  by  a  lantern.  (The  first  tracing 
in  each  case  was  coloured  black,  the  second  red,  the 
third  blue,  so  that  when  they  were  thrown  on  the 
screen  simultaneously,  the  reduction  in  size  was  at 
once  obvious.) 

Of  course,  in  all  diagrams  of  this  kind  allowance 
must  be  made  for  some  unavoidable  exaggeration, 
due  to  the  fact  that  the  tracing  is  taken  on  the  curved 
surface  of  the  thorax  and  is  then  flattened  out  on  a 
plane  surface,  so  that  the  transverse  diameter  of 
the  diagram  is  necessarily  somewhat  longer  than  the 
actual  transverse  diameter  of  the  heart. 

Case  I. — G.  G — ,  aged  34,  admitted  into  St 
Mary's  Hospital  19th  March  1896,  suffering  from 
slight  arthritis  of  the  left  wrist  and  both  shoulders. 
Temperature  on  admission,  100.5";  ^^  the  next  day. 


ILLUSTRATIVE  TRACINGS 


^01 


gcf  ;  on  the  third  day,  98°.     Treatment,  sodium  sali- 
cylate, 20  gr.  every  three  hours. 


G.  G — ,  aged  34.     Rheumatic  fever. 


A 

No.  I. 
March  19,  1896. 


No.  2. 
March  31,  1896. 


April  16,  1896. 


The  first  tracing  shows  the  area  of  cardiac  dullness 
on  his  admission. 

The  second  tracing  was  taken  twelve  days  after 
the  first ;  the  left  border  of  the  dullness  has  now 
retreated  to  the  nipple-line. 

The  third  tracing  was  taken  sixteen  days  after  the 
second,  a  month  after  the  first ;  the  left  border  is  now 
well  within  the  nipple-line, 
also  a  return  to  the  normal. 


The  right  border  shows 


Case  IL — Alfred  H — ,  aged  16  years,  admitted 
3rd  February  1896.  Slight  affection  of  ankles,  knees, 
and  hip-joints.  Temperature  normal.  After  four 
20-gr.  doses  of  salicylate,  the  treatment  was  by  40-gr. 
doses  of  sodium  carbonate  every  two  hours  ;  this  was 
continued  for  a  fortnight. 


The  first  tracing  shows  the  cardiac  area  on  admis- 


sion. 


The  second  tracing  was  taken  ten  days  after  the 
first ;  it  shows  a  diminution  of  two  fingerbreadths  in 


202      ACUTE  DILATATION  OF  THE  HEART 

the  left  margin  of  the  heart,  the  border  now  passing 
through  the  nipple. 

Alfred  H — ,  aged  i6.     Rheumatic  fever. 


The  third  tracing  was  taken  seven  days  after  the 
second  ;  the  heart  has  now  nearly  returned  to  its 
normal  dimensions. 


Case  III. — Albert  R — ,  aged  21  years,  admitted 
6th  March  1896.  Slight  arthritis  of  left  knee,  ankle, 
and  shoulder.  Temperature,  103"^  on  first  evening, 
99''  next  morning ;  some  irregular  pyrexia  continued 
for  fifteen  days.  After  about  six  20-gr.  doses  of  sali- 
cylate the  treatment  was  by  40-gr.  doses  of  sodium 
carbonate  hourly  during  the  daytime. 

Albert  R — ,  aged  21.     Rheumatic  fever. 


0 


A 

No.  2. 
March  11,  1896. 


No.  3. 
March  12,  1 896. 


The  first  tracing  shows  the  cardiac  area  on  admis- 


sion. 


ILLUSTRATIVE  TRACINGS  203 

The  second  tracing  was  taken  four  days  after  the 
first,  and  shows  a  marked  shifting  inwards  of  the  left 
edge  of  dulhiess ;  but  the  area  of  dullness  towards 
the  right  has  somewhat  increased.  This  was  appar- 
ently due  to  an  attack  of  pleurisy,  pleural  friction 
being  plainly  heard.  Leeches  were  applied,  and  in 
the  third  tracing,  taken  on  the  following  day,  the 
right  border  of  the  heart  as  well  as  the  left  has 
returned  to  the  normal  position.  I  have  already  said 
that  I  lay  no  stress  on  the  upper  Hmit  of  these  trac- 
ings, and  I  think  it  possible  that  the  upper  limit  of 
this  third  tracing  may  be  erroneous. 

This  patient  had  been  under  my  care  four  months 
before,  during  a  previous  attack  of  rheumatism.  On 
this  occasion  also  he  had  acute  dilatation  without 
pericarditis  or  endocarditis.  At  first  the  cardiac  dull- 
ness extended  to  one  and  a  half  fingerbreadths,  or 
one  inch,  outside  the  nipple-line.  On  his  recovery 
it  had  become  normal,  and  was  found  half  an  inch 
internal  to  the  nipple. 

The  fourth  set  of  tracings  shows  the  supervention 
of  acute  dilatation  in  a  heart  already  damaged  by 
previous  rheumatism. 

Case  IV. — Harriet  W — ,  aged  14  years,  admitted 
into  St  Mary's  Hospital  loth  March  1896,  suffering 
from  her  third  attack  of  rheumatism.  The  first 
attack  occurred  four  years  before,  the  second  three 
years  before  ;  in  both,  chorea  accompanied  the  rheu- 
matic symptoms.  This  third  attack  commenced  three 
weeks  ago ;  in  it  there  had  been  dyspnoea,  pain 
referred  to  the  heart,  also  pain  in  the  elbows  and  feet. 

On  admission,  temperature,  99°;  pulse,  122;  respira- 
tions, 24.  Fluid  in  both  knees,  ankles  also  swollen. 
Faint  systolic  murmur  at  apex,  and  over  pulmonary 
artery ;    suspicion    of   presystolic    murmur   at   apex. 


204      ACUTE  DILATATION  OF  THE  HEART 

Patient  emotional,  but  not  distinctly  choreic.  Urine 
faintly  acid.  No  salicylate  was  employed  in  this  case, 
the  treatment  being  by  30-gr.  doses  of  sodium  car- 
bonate given  hourly  during  the  daytime. 

The  first  tracing  was  taken  the  day  after  her  admis- 
sion ;  it  shows  the  left  border  of  the  heart  extending 
three  fingerbreadths  outside  the  nipple-line,  and  two 
and  a  half  above  the  nipple,  while  the  right  border  is 
fairly  normal. 


Harriet  W — ,  aged  14.     Rheumatic  fever. 


No.  I. 
March  1 1,  1896. 


No.  3. 
March  16,  1896. 


The  second  tracing,  taken  the  next  day,  is  identical 
with  the  first  on  the  right  side,  but  shows  a  marked 
reduction  on  the  left  side.  The  presystolic  murmur 
was  now  distinct. 

The  third  tracing,  taken  four  days  after  the  second, 
is  similar  to  the  others  on  the  right  side,  but  shows  a 
further  large  reduction  on  the  left  side.  The  urine 
was  now  strongly  alkaline.  A  fourth  tracing,  taken 
nine  days  after  the  third,  is  practically  identical  with 
it ;  she  was  now  taking  the  alkaline  medicine  every 
three  hours,  and  the  urine  had  become  again  faintly 
acid. 

The  third  and  fourth  tracings  represent  doubtless 
the  permanent  increase  in  size  of  her  heart  caused  by 
the  previous  disease,  which  had  left  behind  it  distinct 
slight  stenosis  and  regurgitation  at  the  mitral.     The 


ILLUSTRATIVE  TRACINGS  205 

first  tracing  shows  the   additional   tennporary   acute 
dilatation  of  the  present  attack  of  rheumatism. 

The  fifth  set  of  tracings  shows  the  effect  of  the 
combination  of  acute  dilatation  with  acute  pericarditis. 

Case  V. — Daisy  D — ,  aged  9  years,  was  admitted 
into  St  Mary's  Hospital  7th  February  1896,  suffering 
from  chorea,  pericarditis,  and  slight  arthritis  of  hands 
and  feet.  This  was  her  second  rheumatic  attack. 
Twelve  months  previously  she  had  T^een  an  in-patient 
for  rheumatism,  followed  by  chorea.  On  her  admis- 
sion a  loud  pericardial  rub  and  a  systolic  apex 
murmur  were  heard  by  the  house-physician,  who  at 
once  applied  an  icebag  over  the  heart,  and  ordered 
lO-gr.  doses  of  sodium  salicylate  with  15  gr.  of  sodium 
carbonate  every  four  hours.  I  saw  her  the  next  day 
and  took  the  first  diagram,  which  shows  an  enormous 

Daisy  D — ,  aged  9.     Rheumatic  fever. 


No.  2. 
Feb.  21,  1896. 

increase  of  the  transverse  cardiac  dullness,  the  left 
border  extending  to  more  than  three  fingerbreadths 
outside  the  nipple-line,  and  about  two  above  the 
nipple  ;  the  right  border  also  is  much  too  far  to  the 
right.  It  is  not  unlikely  that  part  of  this  increased 
dullness  was  due  to  the  presence  of  some  pericardial 
effusion.  The  medicine  was  repeated  every  two 
hours.  Next  day  the  frequency  was  altered  to  every 
three  hours,  and  on  the  following  day  (loth)  to  every 


206      ACUTE  DILATATION  OF  THE  HEART 

four  hours.  On  the  iith  the  urine  was  found  to  be 
still  acid,  and  on  the  13th  it  continued  acid,  so  that 
the  medicine  was  again  given  every  three  hours. 
On  the  14th  the  pericardial  rub  had  disappeared  and 
there  was  no  longer  any  chorea,  but  a  loud  systolic 
murmur  was  heard  at  the  apex,  and  pleuritic  friction 
was  detected  in  the  right  axilla.  The  medicine  was 
therefore  given  every  two  hours,  and  a  second  icebag 
was  placed  over  the  anterior  ba.^e  of  the  right  lung. 
Two  days  later,  the  urine  being  still  acid,  the  dose  of 
sodium  carbonate  was  doubled,  and  as  the  pleurisy 
had  disappeared,  the  second  icebag  was  removed 
from  the  right  lung.  On  the  19th  the  urine  had  at 
last  become  alkaline.  On  the  22nd  the  ice-bag  over 
the  heart  was  removed,  having  been  applied  continu- 
ally for  fifteen  days. 

The  second  tracing  was  taken  on  the  21st,  thirteen 
days  after  the  first.  It  shows  an  extraordinary  dimi- 
nution in  the  cardiac  dullness,  and  the  improvement 
in  the  general  condition  corresponded  to  the  improve- 
ment in  the  tracing.  The  pericarditis  had  subsided, 
but  evidence  of  endocarditis  remained.  The  second 
tracing  probably  indicates  the  permanent  cardiac 
enlargement  produced  by  the  first  rheumatic  attack. 
The  great  increase  in  the  precordial  dullness  shown 
in  the  first  tracing  may  have  been  due  in  part  to 
effusion  into  the  pericardium,  but  was  probably 
mainly  due  to  acute  dilatation. 

It  is  worth  while  to  point  out  incidentally  that  in 
this  case,  in  spite  of  the  pericarditis  and  the  dilatation, 
the  free  and  prolonged  administration  of  salicylate  of 
sodium  produced  no  "depressing"  effect. 

I  do  not  claim  that  these  tracings  are  absolutely 
accurate ;  no  doubt  they  are  open  to  criticism  in 
points  of  detail,  and  I  would  again  refer  to  Dr  Ewart's 


OBSERVATIONS  ON  CHILDREN  207 

valuable  papers.  But  they  were  taken  with  care, 
in  all  cases  by  myself,  usually  verified  by  another 
observer,  and  always  without  reference  to  the  preced- 
ing tracing. 

I  think  they  are  sufficient  to  prove  that  an  acute 
dilatation  of  the  heart  does  occur  in  acute  rheu- 
matism ;  that  it  may  be  marked  even  when  there  is 
only  slight  pyrexia  and  but  little  arthritis,  with  no 
modification  of  the  cardiac  auscultatory  phenomena 
beyond  slight  alteration  in  character  of  the  heart- 
sounds  ;  and  that  it  may  complicate  the  evidence  of 
former  heart-disease,  or  of  fresh  endocarditis  or  peri- 
carditis, 

I  made  a  preliminary  statement  of  these  facts  in  a 
letter  to  the  Lancet  of  25th  July  1896,  and  also 
mentioned  therein  that  a  similar  dilatation  occurs  in 
most  cases  of  chorea,  even  when  no  murmur  exists — a 
new  evidence  of  the  essentially  rheumatic  nature  of 
chorea.  Since  that  date  I  have  made  other  observa- 
tions on  rheumatism  in  adults  at  St  Mary's  Hospital, 
and  have  obtained  results  similar  to  those  already 
exhibited.  I  have  made  observations  also  on  the 
occurrence  of  acute  dilatation  of  the  heart  in  the 
rheumatism  and  chorea  of  childhood  at  the  Hospital 
for  Sick  Children,  mainly  in  conjunction  with  my 
friend  Dr  Poynton,  formerly  house-physician  at  that 
hospital,  and  now  medical  registrar  and  pathologist 
at  St  Mary's  Hospital.  We  have  embodied  our 
results    in    a   joint   paper,    illustrated    with    tracings 


208      ACUTE  DILATATION  OF  THE  HEART 

taken  very  carefully  by  Dr  Poynton  and  confirmed 
in  my  own  cases  by  myself.  It  seemed  desirable 
that  the  results  should  be  compared  with  observations 
on  the  hearts  of  children  free  from  rheumatism  and 
cardiac  disease.  Dr  Poynton  therefore  took  tracings 
of  the  cardiac  outline  in  forty-five  children  in  the 
surgical  wards  at  Great  Ormond  Street  during  his 
subsequent  tenure  of  office  as  house-surgeon.  He 
has  also  carefully  examined  the  hearts  of  thirty-five 
healthy  boys,  aged  12  and  13,  at  Marlborough  School, 
with  the  kind  permission  of  Dr  Penny.  Finally,  he 
has  analysed  the  post-mortem  records  of  150  cases  of 
fatal  rheumatic  heart-disease  in  children  under  12. 

I  venture  to  think  that  the  pathological  and  clinical 
results  of  his  researches  and  observations  afford 
additional  and  decisive  proof  of  the  frequency  and 
the  serious  importance  of  rheumatic  dilatation  of  the 
heart. 

The  occurrence  of  acute  dilatation  of  the  heart  in 
rheumatism  has  not  been  entirely  overlooked.  Thus 
Dr  Sansom  writes  {Internatio?tal  Clinics,  1 894,  p.  7) : 
"  I  am  convinced,  however,  that  the  rapid  increases  of 
dullness  over  the  heart  in  rheumatism  are  not  all  due 
to  pericardial  inflammation  and  the  effusion  of  fluid  ; 
the  whole  heart  may  become  swollen  and  dilated — 
swollen  with  the  products  of  inflammatory  exudation, 
dilated  because  of  the  enfeeblement  of  the  muscle  of 
its  right  and  left  chambers.  In  some  cases  this  con- 
dition of  swollen  heart  disappears  without  any  of  the 


OTHER  AUTHORS  209 

friction-signs  of  pericarditis  being  manifested ;  in 
fact,  the  heart  and  its  serous  membranes  may  pass 
through  changes  like  those  occurring  in  a  joint  in- 
flamed through  rheumatism.  These  variations  in  the 
bulk  of  the  heart  may  be  observed  in  some  cases  to 
be  considerable  from  day  to  day,  and  there  may  be 
repeated  enlargement  at  intervals  of  a  few  days,  just 
as  there  may  be  repeated  swelling  iji.the  joints." 

Dr  Samuel  West  reported  to  the  Pathological 
Society  in  1882  the  case  of  an  anaemic  boy  of  16,  who 
died  two  months  after  an  attack  of  rheumatic  fever, 
and  was  found  to  have  dilatation  of  all  the  cardiac 
cavities,  especially  of  the  ventricles.  Evidence  of 
endocarditis  also  existed.  The  myocardium  was 
affected  with  fatty  degeneration. 

At  a  still  earlier  date,  in  1879,  Dr  Goodhart 
exhibited  to  the  same  society  the  heart  of  a  boy  of 
17,  who  died  within  a  month  after  an  attack  which 
was  certainly  rheumatic,  in  whom  the  heart  had 
rapidly  enlarged.  The  left  ventricle  was  "  rather 
widely  dilated."  Weight  of  heart,  19  oz. ;  pericardium 
entirely  adherent  by  soft  lymph ;  recent  valvulitis ; 
muscle  slightly  fatty. 

In  the  same  year,  in  the  Guy's  Hospital  Reports^  Dr 
Goodhart  described  cases  of  acute  dilatation  of  the 
heart  following  scarlet  fever,  and  another  was  published 
in  1880  by  Dr  Barlow  in  the  Medical  Times  and 
Gazette  (1880,  vol.  i.,  p.  426).  In  none  of  these,  how- 
ever, was  there  any  evidence  of  rheumatism.     But  in 

O 


210      ACUTE  DILATATION  OF  THE  HEART 

a  note  appended  to  his  paper,  Dr  Goodhart  adds : 
"  Sir  William  Gull  was  in  the  habit  of  giving  special 
prominence  to  the  fact  that  acute  pericarditis  in  rheu- 
matic fever  is  liable  to  give  rise  to  rapid  dilatation  of 
the  heart,  which  is  often  mistaken  for  pericardial 
effusion.  Sir  W.  Gull  also  taught  that  dilatation  is 
succeeded,  not  preceded,  by  hypertrophy  in  some  of 
these  cases."  "  I  am  very  glad,"  Dr  Goodhart  con- 
tinues, "  to  be  able  to  mention  this,  not  only  because 
it  is  a  weighty  confirmation  of  some  of  the  remarks 
made  in  this  paper  from  another  point  of  view,  but 
also  because  it  has  hitherto  been  unrecorded." 

It  may  perhaps  be  doubted  whether  the  value  of 
these  observations  of  Sir  William  Gull's  has  been 
adequately  appreciated.  At  any  rate,  I  think  that 
the  frequency  and  extent  of  acute  cardiac  dilatation 
in  rheumatic  fever  is  insufficiently  recognised  by  most 
physicians.  Yet  it  is  a  condition  of  great  gravity, 
and  its  presence  or  absence  ought  to  be  carefully 
ascertained  in  every  case  of  the  disease.  When  un- 
complicated with  pericarditis  or  endocarditis,  if  the 
patient  be  kept  absolutely  at  rest  it  may  prove 
transitory,  and  the  heart  may  entirely  recover  itself, 
especially  under  appropriate  medicinal  treatment. 
But  when  it  complicates  pericarditis,  it  adds  enor- 
mously to  the  danger  of  the  latter  condition.  In  the 
more  severe  cases  of  rheumatic  pericarditis,  the 
accompanying  acute  dilatation  is  probably  largely 
responsible   for   the  dangerous  symptoms  of  cardiac 


IMPORTANCE  OF  ACUTE  DILATATION     211 

failure,  for  the  dyspnoea,  the   tendency  to    cyanosis, 
the  feeble  pulse,  and  the  deHrium. 

When  the  pericarditis  is  over,  and  has  ended  in 
pericardial  adhesion,  the  heart  becomes  fixed  in  its 
dilated  state,  and  it  is  never  again  able  to  return  to 
the  normal.  Some  amount  of  hypertrophy  may  follow, 
enough  to  maintain  compensation,  in  the  absence  of 
much  exertion,  for  a  limited  time-; -but  such  hearts 
are  permanently  crippled,  and  soon  break  down. 
Cases  of  this  kind  are  only  too  frequent  in  children 
and  young  adults. 

Acute  dilatation  is  probably  a  much  more  important 
factor  than  endocarditis  in  the  production  of  many 
cases  of  chronic  heart-disease.  In  a  girl  recently 
under  my  care  at  Great  Ormond  Street,  enormous 
dilatation  of  the  heart  was  produced  in  six  months 
after  the  first  illness.  She  died  from  pericarditis ;  it 
was  found  after  death  that  there  was  no  fluid  in  the 
pericardial  sac,  but  recent  adhesions  everywhere. 
There  was  some  mitral  endocarditis,  but  it  was  very 
slight,  and  entirely  inadequate  to  account  for  the 
remarkable  dilatation  of  the  ventricles.  If  this  patient 
had  survived,  and  come  under  observation  at  a  later 
period  with  an  enlarged  heart  and  a  systolic  apex- 
murmur,  it  is  almost  certain  that  the  cardiac  dilatation 
would  have  been  considered  the  consequence  of  her 
mitral  insufficiency.  It  is  probable  that  very  many 
cases  of  chronic  heart-disease  now  attributed  to 
"  mitral  regurgitation  "  or  to  "  adherent  pericardium  " 


212      ACUTE  DILATATION  OF  THE  HEART 

are  essentially  the  permanent  results  of  an  acute  dilata- 
tion, the  pericardial  adhesions  and  the  valvular  damage 
taking  but  a  small  share  in  the  morbid  process. 

It  is  unlikely  that  many  cases  of  the  acute  dilatation 
above  described  are  due  to  definite  myocarditis.  No 
doubt  this  is  a  possible  cause,  and  it  was  present  in  a 
case  recently  reported  (with  autopsy)  to  the  Clinical 
Society  by  Dr  Herringham.  But  the  transitory 
nature  of  the  affection  under  appropriate  treatment, 
as  shown  by  the  tracings  now  exhibited,  seems  to 
prove  that  in  these  there  cannot  have  been  any  actual 
inflammation,  though  there  may  have  been  an  acute 
congestion,  of  the  muscle.  It  is  possible  that  skilled 
microscopical  examination  may  reveal  some  change 
in  the  nutritive  condition  of  the  cardiac  muscular 
fibre  generally,  but  whether  this  be  so  or  not,  it  seems 
likely  that  the  effect  is  a  toxic  one. 

Sixteen  years  ago  {Journal  of  Physiology^  vol.  iii.), 
Dr  Gaskell  proved  that  a  dilute  solution  of  sodium 
hydrate  caused  gradual  progressive  contraction  of  the 
frog's  ventricle  until  it  remained  persistently  fully 
contracted  and  failed  to  relax  at  all ;  it  caused  also  a 
similar  contraction  of  the  arterioles.  On  the  other 
hand,  a  dilute  solution  of  lactic  acid  caused  relaxation 
and  "  extreme  dilatation  "  of  the  ventricle,  and  finally 
diastolic  standstill  ;  it  caused  relaxation  also  of  the 
vessels.  He  investigated  the  action  of  various  drugs, 
and  found  that  some  of  them  acted  like  soda,  others 
like  lactic  acid. 


ACTION  OF  SODIUM  CARBONATE  213 

These  experiments  seem  to  suggest  that  the  pro- 
duction of  the  remarkable  cardiac  dilatation  which 
occurs  in  rheumatism  may  be  due  to  the  presence  in 
the  circulating  blood  of  a  poison  acting  on  the  heart 
like  lactic  acid.  May  not  this  be  the  toxin  resulting 
from  the  development  of  a  micro-organism  ?  It  can 
hardly  be  doubted  that  this  is  the  true  explanation  of 
the  acute  and  sometimes  fatal  dilatation  of  the  heart 
which  occurs  in  influenza.  The  more  carefully  rheu- 
matism in  childhood  is  studied,  the  more  reason  will 
be  found  for  the  belief  that  it  cannot  be  due  to  any 
mere  perversion  of  metabolism,  but  must  be  due  to 
some  microbic  process. 

The  suggestive  observation  of  Dr  Gaskell  as  to  the 
influence  of  soda  in  causing  cardiac  contraction  seemed 
to  me  to  afford  reason  for  hope  that  this  alkali  might 
be  found  of  service  in  diminishing  the  dilating  effect 
of  the  rheumatic  toxin.  I  have  therefore  treated 
some  cases  with  large  and  frequent  doses  of  sodium 
carbonate,  and  I  have  thought  that  a  more  rapid 
shrinking  of  the  enlarged  area  of  cardiac  dullness 
occurred  in  these  cases  than  in  those  treated  with 
salicylates  alone.  The  plan  seems  to  me  worthy  of 
further  trial.  At  all  events  I  found  that  the  drug 
was  well  tolerated  in  spite  of  its  unpleasant  taste,  that 
it  never  caused  vomiting  or  lessened  appetite  in  rheu- 
matic subjects,  and  that  large  doses  were  required  to 
render  the  urine  alkaline.  I  selected  the  carbonate 
in  order  to  secure  as  large  an  amount  as  possible  of 


214      ACUTE  DILATATION  OF  THE  HEART 

the  sodium  element,  forgetting  for  the  time  that  the 
water  of  crystallisation  contained  in  it  makes  it  really 
less  powerful  as  an  antacid  than  the  bicarbonate.  I 
am  now  making  further  observations  upon  the  action 
of  the  bicarbonate. 


RHEUMATIC  HEART-DISEASE  IN 
CHILDREN. 

( The  Introduction  to  a  Discussion  in  the  Section  of  Diseases  of 
Children  at  the  Edinburgh  Meeting  of  the  British  Medical 
Association^  fuly  1898.) 

'     Rheumatic  Carditis. 

The  disease  which,  for  want  of  a  better  term,  we  still 
call  "  acute  rheumatism,"  is  one  of  the  chief  destroyers 
of  children.  Those  who  study  it  only  in  adults  can  have 
but  very  inadequate  ideas  of  its  virulence  in  child- 
hood. In  adults  it  is  rare  for  a  fatal  result  to  be 
caused  directly  by  a  rheumatic  attack ;  in  children  it 
is  much  less  uncommon.  My  friend  Dr  Poynton  col- 
lected from  the  post-mortem  records  of  the  Hospital 
for  Sick  Children  and  of  St  Mary's  Hospital  1 50  cases 
of  fatal  rheumatic  heart-disease  in  children ;  in  nearly 
one-third  of  these  (35  of  1 15  available)  the  fatal  attack 
was  the  first  that  had  occurred.  He  found  also  that 
of  100  cases,  the  clinical  history  of  which  was  recorded 
with  sufficient  details,  as  many  as  Z6  had  exhibited 
symptoms  of  fresh  rheumatism  during  the  fatal  attack, 

215 


216    RHEUMATIC  HEART-DISEASE  IN  CHILDREN 

indicating  that  death  in  the  majority  of  instances  was 
caused  not  simply  by  previous  heart-disease,  but  in 
part  by  a  recent  toxic  process. 

Acute  rheumatism  in  childhood,  not  so  obviously 
and  rapidly  fatal  as  this,  often  does  such  serious 
damage  that  the  patient  dies  during  adolescence  or  in 
early  adult  life.  This  destruction  is  brought  about  by 
the  pernicious  action  of  the  rheumatic  poison  upon  the 
heart.  In  the  Lumleian  Lectures  for  1894  my  late 
colleague,  Dr  Sturges,  drew  attention  to  the  frequency 
and  fatality  of  rheumatic  ''  carditis,"  and  stated  that 
of  sixteen  cases  of  this  severe  type  which  he  remem- 
bered twelve  died. 

Endocarditis. 

The  fatal  result  is  not,  as  a  rule,  due  to  endocarditis. 
Evidence  of  recent  or  of  former  valvulitis  is  indeed 
almost  invariably  found  in  the  hearts  of  children  dead 
from  rheumatic  heart-disease,  but  it  is  often  quite 
slight  in  amount,  and  can  have  been  only  a  minor 
factor.  The  mitral  valve  was  implicated  in  all  but  one 
of  the  cases  analysed  by  Dr  Poynton,  but  in  seventy- 
six  the  damage  to  this  valve  was  apparently  very 
slight,  and  consisted  only  in  some  thickening  or  small 
vegetations.  Marked  thickening  and  puckering  of 
the  valve  segments  was  recorded  in  only  three  cases, 
and  marked  mitral  stenosis  in  only  nine.  "  Marked 
mitral  regurgitation "  was  recorded  in  eleven  cases, 
but   it  is  not  unlikely  that  in  many  of  these  it  was 


ENDOCARDITIS  AND  PERICARDITIS       217 

really  due  to  dilatation  of  the  orifice  rather  than  to 
defornaity  of  the  valve  segments. 

The  aortic  valve  is  implicated  much  less  frequently 
than  the  mitral.  In  the  150  cases  analysed  it  was 
affected  in  only  51,  or  34  per  cent,  and  in  only  9  of 
these  was  the  affection  more  than  slight. 

Pericarditis.    .  . 

Pericarditis  is  a  much  more  striking  phenomenon 
than  endocarditis  in  the  post-mortem  appearances  of 
rheumatic  heart-disease  in  children,  and  probably  con- 
tributes much  more  largely  to  the  fatal  result.  In 
only  9  of  the  1 50  cases  is  it  definitely  stated  that  the 
pericardium  was  healthy.  It  was  found  to  be  more  or 
less  adherent  in  113  cases  (75  per  cent),  and  in  77  of 
these,  or  one-half  of  the  entire  number,  the  adhesion 
was  complete  over  the  whole  surface  of  the  heart 
It  is  clear,  therefore,  that  more  than  50  per  cent,  of 
the  fatal  cases  have  suffered  from  severe  pericarditis, 
and  this  is  doubtless  a  very  considerable  factor  in  the 
arrest  of  the  heart's  action.  How  pericarditis  pro- 
duces this  pernicious  effect  is  well  worthy  of  considera- 
tion. It  will  probably  surprise  many  to  learn  that  it 
is  rarely  by  the  effusion  of  any  great  amount  of  fluid 
into  the  pericardial  cavity.  The  figures  with  reference 
to  this  are  very  instructive.  In  only  38  cases  of  the 
150,  or  25  per  cent,  is  it  noted  that  any  fluid  at  all 
was  present  in  the  pericardial  cavity,  and  in  many  of 
these  the  amount  was  small.     In  not  more  than  twelve 


218    RHEUMATIC  HEART-DISEASE  IN  CHILDREN 

was  the  amount  estimated  at  more  than  2  oz.,  and  in 
only  six  at  more  than  3  oz.  The  highest  estimates 
were  5  and  6  oz.,  and  each  of  these  in  one  case  only. 

These  facts  show  that  "pericardial  effusion"  in 
rheumatic  fever  is  of  much  less  frequency,  amount,  and 
importance,  than  would  naturally  be  inferred  from  the 
statements  of  the  text-books,  and  that  the  disastrous 
effects  of  pericarditis  are  not  produced  by  mere  effusion 
of  fluid. 

To  understand  how  pericarditis  kills,  it  is  necessary 
to  examine  carefully  the  condition  of  the  muscular 
wall  of  the  heart.  The  visceral  pericardium  is  really 
part  of  the  heart  itself ;  its  interstitial  connective 
tissue  is  continuous  with  that  of  the  cardiac  muscle, 
and  the  cardiac  nerves,  vessels,  and  lymphatics  course 
in  the  subpericardial  tissue.  It  is  hardly  possible  for 
the  pericardium  to  be  inflamed  without  some  damage 
to  the  superficial  part  of  the  cardiac  wall.  Careful 
observations  are  greatly  needed  to  determine  whether 
this  damage  is  always  appreciable  by  the  microscope, 
how  deeply  it  penetrates,  and  whether  it  is  more  in- 
tense in  the  neighbourhood  of  the  fibrous  valve-ring 
than  elsewhere.  But  an  investigation  of  this  kind 
is  difficult,  and  a  satisfactory  result  will  probably  not 
be  attained  without  improvements  in  our  present  histo- 
logical methods.  Meanwhile,  it  is  important  to  observe 
whether  any  gross  changes  in  the  cardiac  muscular 
wall  are  revealed  by  post-mortem  examination  of  fatal 
rheumatic  heart-disease  ;  and  on  this  matter  Dr  Poyn- 


DILATATION  AND  HYPERTROPHY         219 

ton's  analysis  yields  some  valuable  information.  In 
34  of  the  150  records  analysed,  or  23  per  cent,  the 
existence  of  some  morbid  condition  of  the  myocardium 
is  specially  mentioned.  In  13  of  these  it  was  soft  and 
pale,  in  4  fatty,  in  8  tough  and  fibroid.  These  state- 
ments suggest  that  if  a  careful  microscopical  examina- 
tion had  been  made  in  each  of  the  150  cases,  some 
evidence  of  myocardial  change  •  would  have  been 
detected  in  a  considerable  number. 

Two  important  consequences  may  possibly  follow 
from  the  injury  to  the  muscular  wall  of  the  heart  by 
the  pericardial  inflammation.  The  weakened  cardiac 
muscle  may  be  stretched  by  the  internal  blood-pres- 
sure, and  the  heart  become  dilated.  Such  dilatation, 
allowing  a  larger  quantity  of  blood  in  the  ventricles 
during  diastole,  will  give  the  heart  a  harder  task 
during  systole,  and  may  thus  lead  to  hypertrophy. 
It  becomes  of  interest,  therefore,  to  ascertain  whether 
these  results  are  apparent  in  the  post-mortem  records. 
Dr  Poynton  found  special  mention  of  hypertrophy 
in  58  of  the  150  cases.  But  special  mention  of  dilata- 
tion was  found  in  no  fewer  than  92  cases,  and  of  these 
56  were  markedly  dilated.  Thus  it  is  clear  that  dilata- 
tion is  a  much  more  common  and  striking  pheno- 
menon than  hypertrophy  in  the  hearts  of  children 
who  have  died  from  rheumatic  heart-disease.  And 
it  is  possible  that  the  disproportion  may  be  even 
greater  than  appears  at  first  sight,  for  it  is  quite 
likely  that  some  of  the  "  hypertrophy  "  may  not  be 


220   RHEUMATIC  HEART-DISEASE  IN  CHILDREN 

genuine,  but  merely  a  thickening  of  the  cardiac  wall 
by  oedema  and  inflammatory  change,  and  thus  be 
not  compensatory,  but  only  a  further  evidence  of 
cardiac  weakness. 

The  Main  Causes  of  the  Large  Mortality. 

The  conclusions  to  be  drawn  from  this  analysis 
seem  to  be  that  endocarditis  and  pericardial  effusion 
have  very  little  share  in  the  production  of  the  fatal 
result  in  the  rheumatic  heart-disease  of  early  life,  and 
that  the  main  factors  responsible  for  the  mortality 
and  for  a  large  part  of  the  cardiac  crippling  in  those 
who  survive  are  (i)  pericarditis  of  plastic  type;  and 
(2)  dilatation  of  the  heart. 

These  facts  ought  to  be  carefully  kept  in  mind 
when  we  proceed  to  examine  clinically  the  heart  of 
a  child  suffering  from  rheumatism.  Let  us  remember 
that  murmurs  are  of  comparatively  small  importance 
in  the  immediate  prognosis,  and  that  the  points  which 
it  is  essential  to  determine  are  :  (i)  evidence  of  peri- 
cardial friction  ;  and  (2)  evidence  of  cardiac  dilata- 
tion. With  regard  to  the  first  of  these  points,  it  is 
hardly  necessary,  before  the  present  audience,  to  say 
anything. 

Cardiac  Dilatation. 

But  it  seems  desirable  to  direct  special  attention 
to  the  question  of  cardiac  dilatation.  I  have  hitherto 
spoken  of  this  only  in   connection  with   pericarditis, 


MAIN  CAUSES  OF  THE  MORTALITY        221 

and  it  certainly  often  accompanies  that  condition.  I 
discovered  this  for  myself  while  studying  the  curative 
influence  of  the  icebag  in  pericarditis,  not  then  know- 
ing that  it  had  been  pointed  out  by  Sir  William  Gull 
years  ago.  It  seemed  at  first  easy  to  explain  the 
dilatation  by  the  weakening  effect  of  pericarditis  on 
the  cardiac  muscle.  But  further  study  soon  showed 
that  this  was  not  the  complete  explanation,  for  I  found 
that  more  or  less  dilatation  is  usually  present  in  a 
rheum^atic  attack  in  which  there  is  no  proof  of  either 
pericarditis  or  endocarditis ;  in  subacute  first  attacks 
with  slight  pyrexia  and  little  arthritis  ;  in  adults  as 
well  as  in  children.  By  careful  light  percussion  it  is 
generally  easy  to  demonstrate  a  decided  increase  in 
the  area  of  deep  cardiac  dullness,  especially  towards 
the  left,  and  a  shifting  of  the  left  margin  of  the  heart 
outwards,  so  that  it  passes  no  longer  within  the  nipple- 
line,  but  through  the  nipple,  or  outside  and  above  it. 
The  cardiac  impulse  is  enfeebled  and  diffused,  and 
the  site  of  the  maximum  impulse  shifted  towards  the 
left,  into  the  nipple-line,  or  even  external  to  it,  though 
not  so  far  to  the  left  as  the  left  margin  of  dullness. 
The  first  sound  becomes  somewhat  altered  in  char- 
acter. There  may  be  no  murmur  at  all,  or  only  a 
faint  blowing  systolic  murmur  over  the  right  ven- 
tricle, such  as  occurs  not  rarely  in  apparently  healthy 
children. 

Tracings  shown  by  Dr  Poynton  and  myself  at  the 
last  meeting  of  the   Royal  Medical  and  Chirurgical 


222    RHEUMATIC  HEART-DISEASE  IN  CHILDREN 

Society,  and  to  be  published  in  the  next  volume  of 
its  Transactions^  show  that  in  all  there  is  evidence  of 
dilatation  of  the  left  side  of  the  heart,  sometimes  of 
the  right  side  also ;  that  the  dilatation  tends  to 
diminish  as  the  rheumatic  symptoms  subside,  and 
that  it  may  increase  again  if  the  rheumatism  relapses. 

It  is  clear  from  evidence  of  this  kind  that  dilatation 
of  the  heart  is  a  common  phenomenon  in  rheumatism, 
and  that  it  is  by  no  means  limited  to  the  cases  which 
suffer  from  pericarditis,  though  it  may  become  much 
more  pronounced  when  pericarditis  is  present  It 
appears  to  be  due  to  a  toxic  action  of  the  rheumatic 
poison  on  the  cardiac  muscle.  A  similar  acute  dilata- 
tion occurs  in  influenza,  and  is  often  the  cause  of 
severe  symptoms,  sometimes  of  a  fatal  result.  Both 
in  influenza  and  in  rheumatism  the  cardiac  dilatation 
caused  by  the  acute  attack  may  remain  when  the 
attack  is  over,  gradually  producing  symptoms  of 
increasing  cardiac  failure,  and  death  a  few  years 
afterwards.  It  cannot  be  doubted  that  in  influenza 
the  deleterious  action  on  the  heart  is  the  effect  of  a 
toxin  produced  by  a  microbic  growth  ;  it  seems  highly 
probable  that  the  same  is  true  for  rheumatism. 

A  child  who  has  once  suffered  from  rheumatism  is 
very  liable  to  have  subsequent  attacks.  Often  the 
dilatation  caused  by  the  first  attack  has  not  subsided 
when  the  second  attack  occurs,  and  causes  further 
dilatation.  The  heart  may  thus  become  of  very  large 
size  ;  the  dullness  may  extend  as  far  as  three  or  even 


PERICARDIAL  EFFUSION  223 

four  fingerbreadths  to  the  left  of  the  nipple,  the  left 
margin  crossing  the  nipple-line  two  or  even  three 
fingerbreadths  above  the  nipple  ;  and  it  may  extend 
two  or  even  three  fingerbreadths  to  the  right  of  the 
sternum  in  the  fourth  right  space.  Upwards  it  may 
extend  as  high  as  the  upper  border  of  the  second  left 
costal  cartilage,  without  any  pericardial  effusion. 

Pericardial  Effusioti. 

Sometimes,  doubtless,  the  presence  of  more  or  less 
fluid  in  the  pericardial  cavity  further  increases  the 
precordial  dullness,  but  usually  the  major  part  of  the 
enlargement,  and  often  the  whole  of  it,  is  due  to 
dilatation.  The  figures  quoted  above  show  how 
rarely  any  considerable  quantity  of  fluid  is  found  in 
the  pericardial  cavity  after  death.  Is  it  possible  to 
determine  clinically  with  any  certainty  whether  peri- 
cardial effusion  is  present  in  addition  to  the  dilatation  ? 
In  this  connection  Dr  Sansom  lays  stress  on  a  con- 
siderable extension  of  dullness  in  the  third  and  second 
intercostal  spaces.  This  sign  is  of  value,  for  the  fibro- 
serous  inflammatory  product  of  early  rheumatic  peri- 
carditis is  most  abundant  at  the  base  of  the  heart, 
around  the  great  vessels.  It  has  been  suggested  that 
dullness  in  the  fifth  right  space  is  indicative  of  fluid 
in  the  pericardium,  but  this  is  certainly  incorrect,  for 
it  may  be  caused  by  dilatation  of  the  right  auricle. 
Dr  Ewart  thinks  that  fluid  in  the  pericardial  cavity 
distends  the  pericardial  sac  at  its  attachment  to  the 


224   RHEUMATIC  HEART-DISEASE  IN  CHILDREN 

diaphragm,  and  that  the  right  and  left  margins  of 
the  precordial  dullness  then  slope  outwards  as  they 
descend,  meeting  the  horizontal  line  of  absolute  liver 
dullness  at  an  acute  angle.  The  fact  of  cardiac  dilata- 
tion accompanying  rheum. atic  pericarditis  makes  this 
point  very  difficult  to  determine  with  accuracy,  and 
practically  deprives  it  of  value.  Nor  has  any  post- 
mortem evidence  been  adduced  to  prove  that  the 
presence  of  fluid  in  the  pericardium  could  produce 
such  angular  outlines. 

In  the  treatment  of  an  acute  rheumatic  attack  it 
is  extremely  important  to  remember  that  a  rapid 
increase  in  the  area  of  precordial  dullness,  which  is 
very  liable  to  be  attributed  to  effusion  into  the  peri- 
cardium, is  mainly  due  to  acute  dilatation  of  the  heart, 
and  may  be  wholly  due  to  it. 

Chronic  Dilatatio7i. 

In  chronic  heart-disease  resulting  from  former 
rheumatic  attacks,  chronic  cardiac  dilatation,  the  per- 
manent result  of  a  former  acute  dilatation,  plays  a 
large  part.  If  during  life  there  is  evidence  of 
adhesion  of  the  pericardium,  or  if  such  adhesion  is 
found  after  death,  the  damage  to  the  heart  is  usually 
attributed  to  "  adherent  pericardium."  When 
external  pericardial  adhesions  exist,  fixing  the  heart 
to  the  sternum,  pleurae,  and  lungs,  there  can  be 
little  doubt  that  these  have  an  injurious  effect,  especi- 
ally if  they  at  all  constrict  the  great  vessels.     But  it  is 


SYSTOLIC  AND  PRESYSTOLIC  MURMURS    225 

doubtful  whether  simple  adhesion  of  the  two  peri- 
cardial surfaces  does  much  harm,  except  in  this 
respect :  that  it  tends  to  render  permanent  an  acute 
dilatation  and  to  hinder  its  diminution. 

Systolic  and  Presystolic  Murmurs. 

If,  again,  as  is  often  the  case,  along  with  the  per- 
manent dilatation,  a  systolic  murmur  at  the  apex  is 
audible,  the  symptoms  are  usually  thought  to  be  due 
to  "  mitral  regurgitation  "  pure  and  simple.  Now  it 
can  hardly  be  doubted  that  a  persistent  and  unvary- 
ing systolic  murmur  at  the  apex,  conducted  towards 
the  axilla,  is  good  evidence  of  more  or  less  regurgita- 
tion through  the  mitral  orifice,  and  it  seems  certain 
that  mitral  regurgitation,  by  causing  increased  intra- 
auricular  tension,  and  therefore  increased  intraven- 
tricular tension  during  diastole,  must  tend  to  produce 
some  dilatation  and  hypertrophy  of  the  ventricle. 
But  it  is  probable  that  a  large  part  of  the  dilatation 
observed  in  chronic  heart-disease  resulting  from  acute 
rheumatic  attacks  is  not  really  due  to  the  co-existing 
mitral  regurgitation,  but  that  both  dilatation  and 
regurgitation  are  persisting  effects  of  the  acute 
attack  ;  the  former  due  to  its  poisonous  influence  on 
the  cardiac  muscle,  the  latter  to  the  synchronous 
endocarditis.  It  has  often  been  noticed  in  necropsies 
on  cases  of  "  mitral  regurgitation  "  that  the  apparent 
damage  to  the  mitral  valve  is  far  too  slight  to  account 
satisfactorily    for   the    symptoms    of    cardiac    failure. 


226    RHEUMATIC  HEART-DISEASE  IN  CHILDREN 

Probably  in  such  cases  it  has  played  only  a  minor 
part  in  producing  such  failure,  the  main  cause  having 
been  the  persistent  dilatation  remaining  after  the 
original  rheumatism.  Thus  it  is  easy  to  attribute  too 
much  importance  to  the  presence  of  a  systolic  apex- 
murmur  ;  the  prognosis  depends  far  less  on  this  than 
on  evidence  as  to  the  size  and  strength  of  the  heart. 

The   meaning   and    importance    of    a    presystolic 
murmur   in    a   child    requires    careful   consideration. 
We  may  best  arrive  at  the  truth  by  carefully  watch- 
ing its   development   as   the   result   of  a   rheumatic 
attack.     The  first  indication  of  endocarditis  is  always 
the  appearance  of  a  systolic  murmur  at  the  apex,  the 
second  sound  being  still  audible.     In  many  cases  it 
may  be  observed  that  after  a  time  this  second  sound 
becomes   doubled,   so   that   the   systolic    murmur   is 
followed   by  two  second    sounds   of  similar   quality, 
which  may  be  indicated  by  the  symbol  "  whoo-ta-ta." 
This  doubling  is  only  heard  in  the  apex  region,  it  is 
not  audible  at  the   base  ;  it  is,  therefore,  a  different 
thing  from  the  reduplicated  second  sound  often  heard 
over  the  base  in  cases  of  advanced  mitral  stenosis. 
No  explanation  of  its  production  that  I  have  seen  has 
seemed  to  me  quite  satisfactory.     I  believe  that  the 
first  of  these  two  sounds  is  the  normal  second  sound 
of  the  heart,  compounded  of  the  aortic  and  the  pul- 
monary   second   sounds.       This    is    caused,   not   by 
forcible  closure  of  the  aortic  and  pulmonary  valves,  but 
by  the  sudden  extra   strain  thrown  on    the  already 


DOUBLE  SECOND  SOUND  227 

closed  valves  and  on  the  aorta  and  pulmonary  artery 
by  the  diastolic  expansion  of  the  ventricles.  I  think 
that  the  second  of  the  two  sounds,  similar  in  quality 
to  the  first,  is  caused  by  the  tension  of  inflamed  and 
stiffened  mitral  flaps  produced  by  the  same  rapid 
expansion  of  the  ventricle.  The  observations  of 
Ludwig  and  Hesse  quoted  by  Dr  MacAlister  {B.MJ., 
1882),  show  that  in  the  healthy  heart  during  full  dia- 
stole the  mitral  flaps  do  not  "  hang  loosely  down,  but 
are  stretched  taut  from  basal  ring  to  muscle-tip."  The 
rapid  expansion  of  the  ventricle,  caused  by  its  elastic 
rebound  after  systole  and  by  the  rapid  filling  of  the 
cardiac  vessels,  carries  with  it  the  papillary  columns 
implanted  in  the  ventricular  wall,  and  thus  through  the 
chordae  tendineae  tends  to  fix  and  stretch  the  mitral 
flaps.  If  any  sound  is  normally  produced  by  this 
sudden  tension  of  the  mitral  and  tricuspid  valves,  it 
will  coincide  in  time  with  the  sound  caused  by  the 
sudden  strain  on  the  aortic  and  pulmonary  valves  by 
the  sudden  diminution  of  pressure  below  them,  and 
will  thus  form  a  part  of  the  normal  second  sound. 
Now,  if  the  mitral  flaps  are  thickened  by  inflammation, 
they  will  be  somewhat  more  slow  to  move,  and  it  may 
well  be  that  it  will  take  a  little  longer  to  stretch  them 
fully,  and  the  sound  produced  by  their  tension  will  no 
longer  accurately  coincide  with  the  sound  of  the 
strained  valves  at  the  root  of  the  vessels,  and  may  be 
so  much  delayed  as  to  be  distinguished  by  the  ear  as 
a  second  "  second  sound." 


228    RHEUMATIC  HEART-DISEASE  IN  CHILDREN 

The  first  element  of  the  double  second  sound  at  the 
apex  never  alters  in  character — it  always  remains  a 
sharp  short  sound  so  long  as  it  is  audible  at  all.  But 
the  second  element  is  liable  to  alteration ;  in  place  of 
a  sharp  short  sound  a  short  blowing  murmur  becomes 
audible.  The  descriptive  symbol  is  no  longer  "  whoo- 
ta-ta,"  but  "  whoo-ta-who."  The  time  of  this  murmur 
in  the  cardiac  rhythm  would  be  described  by  some 
observers  as  "  early  diastolic,"  by  others  as  "  mid- 
diastolic." It  is  doubtless  produced  by  a  slight  vibra- 
tion of  the  stiffened  mitral  flaps  caused  by  the 
commencing  inrush  of  blood  from  the  auricle,  resulting 
from  the  suction-action  of  the  rapid  ventricular 
expansion.  It  will  sometimes  be  noticed  that  the 
rhythm  of  the  murmur  seems  to  change  when  one 
listens  over  the  cardiac  septum,  a  little  internal  to  the 
apex  ;  here  the  murmur  may  distinctly  precede  the 
systole  instead  of  following  it — it  is  presystolic.  This 
must  be  due  to  the  contraction  of  the  auricle  forcing 
a  stronger  blood-stream  against  the  thickened  mitral 
flap.  At  a  later  stage,  there  may  be  at  the  apex  a 
systolic,  immediately  followed  by  a  short  early 
diastolic,  murmur,  or  a  short  presystolic  followed  by  a 
longer  and  louder  systolic.  It  should  be  carefully 
noted  that  this  presystolic  is  of  a  blowing  character, 
and  usually  short.  The  combination  of  a  short  pre- 
systolic and  a  long  systolic — both  of  blowing  character, 
the  systolic  often  the  harsher  of  the  two — is  common 
in  children  after  a    rheumatic  attack.     It  is    usually 


AORTIC  MURMURS  229 

accompanied  with  evidence  of  great  dilatation  of  the 
heart.  It  must  not  be  taken  to  mean  definite  mitral 
stenosis.  A  necropsy  shows  a  dilated  heart,  with  or 
without  pericarditis  ;  and  little  or  no  contraction  of 
the  mitral  orifice,  though  the  valve-flaps  will  be  found 
to  be  opaque  and  somewhat  thickened  and  stiffened. 
Occasionally  the  presystolic  murmur  becomes  a  little 
vibratile,  or  very  slightly  rumbUng ;  it  may  end 
sharply  with  the  systole,  or  it  may  be  prolonged 
backwards  and  occupy  the  greater  part  of  the  diastole. 
But  it  very  rarely  has  the  loud,  rough,  churning  char- 
acter of  the  presystolic  murmur  often  found  in 
children  over  15  or  in  young  adults.  And  the  analy- 
sis quoted  above  shows  that  marked  mitral  stenosis  is 
quite  rare  in  children  under  12  ;  in  the  150  necropsies 
it  was  found  only  nine  times.  The  narrowing  of  the 
orifice  is  a  slow  process ;  it  takes  years  for  its  full 
development. 

Aortic  Murmurs. 

Aortic  murmurs  are  in  young  children  much  rarer 
than  mitral  ones,  and  are  of  very  little  value  in  the 
immediate  prognosis.  They  may  indeed  be  accom- 
panied by  great  cardiac  dilatation,  and  by  a  sudden, 
large,  somewhat  collapsing  pulse.  But  these  pheno- 
mena may  be  present  in  as  great  amount  when  the 
aortic  valves  are  unaffected.  The  dilatation  is  of  the 
greatest  importance  as  an  element  in  the  prognosis, 
but  any   actual    aortic  regurgitation  is   usually  very 


230   RHEUMATIC  HEART-DISEASE  IN  CHILDREN 

slight  and  of  no  immediate  importance.  Care,  how- 
ever, should  be  taken  not  to  put  down  to  commencing 
aortic  disease  a  soft  double  sound  at  the  base,  which 
may  be  the  first  indication  of  pericarditis.  Such  an 
error  is  doubly  unfortunate,  for  the  exocardial  lesion 
is  much  the  more  serious  of  the  two,  and  it  also  is 
much  more  open  to  active  treatment. 

Conclusions. 

To  sum  up,  I  would  assert  that  the  prognosis  in 
rheumatic  heart-disease  in  young  children  is  not  to 
be  deduced  from  a  consideration  of  the  valvular 
lesions  believed  to  be  present,  except  in  the  very  rare 
cases  of  advanced  mitral  stenosis  ;  but  that  it  must  be 
founded  mainly  on  three  facts — the  amount  of  cardiac 
dilatation,  the  presence  or  absence  of  pericarditis,  and 
the  evidence  of  a  fresh  rheumatic  toxaemia,  as  shown 
by  sore  throat,  erythema,  rheumatic  nodules,  arthritis, 
and  chorea. 


AN  ADDRESS  ON  ACUTE  DILATATION 
OF  THE  HEART  IN  '  DIPHTHERIA, 
INFLUENZA,  AND  RHEUMATIC 
FEVER. 

(^Delivered  before  the  Manchester  Medical  Society^  October  1900.) 

Sudden  Death  during  and  after  Diphtheria. 

It  is  a  fact  of  common  knowledge  that  sudden  death, 
often  quite  unexpected,  is  sometimes  the  result  of  an 
attack  of  diphtheria  in  a  child.  Most  medical  prac- 
titioners of  ten  years'  standing  have  seen  or  heard  of 
a  case  in  which  this  has  happened.  Let  me  briefly 
refer  to  a  few  instances  which  I  have  myself  met 
with,  or  which  have  been  related  to  me  by  trustworthy 
observers. 

Case  I. — When  I  was  a  clinical  clerk,  a  young  girl 
was  admitted  into  hospital  one  afternoon  on  account 
of  weakness  after  diphtheria.  She  sat  up  in  bed,  and 
did  not  seem  ill.  When  I  came  next  morning  to 
take  notes  of  her  condition,  she  was  dead. 

Case  II. — Some  years  after  this,  when  I  was  in 
charge   of    out-patients    at    St    Mary's    Hospital,   I 

231 


232    ACUTE  DILATATION  OF  THE  HEART,  ETC. 

admitted  under  my  own  care  (by  the  kindness  of  Sir 
William  Broad  bent)  a  child  suffering  from  diphtherial 
paralysis.  I  saw  it  in  the  ward  the  same  afternoon, 
and  perceived  no  cause  for  apprehension.  When  I 
came  to  visit  it  next  morning,  it  was  dead. 

Case  III. — A  child  of  3  years  of  age  had  suffered 
from  diphtheria,  but  was  thought  to  be  convalescent. 
She  was  standing  by  a  window,  when  some  one 
entered  the  room  a  little  abruptly.  She  turned 
quickly  round,  and  fell  dead  on  the  floor. 

Case  IV. — A  medical  man  in  good  practice  attended 
a  child  for  diphtheria.  As  she  did  not  recover  as 
quickly  as  he  expected,  he  sent  her  to  the  seaside  for 
change  of  air.     She  fell  dead  on  the  sands. 

Cases  V.  and  VI. —  Another  medical  man  had  two 
little  patients  suffering  from  diphtheria.  When  one 
of  them  seemed  convalescent,  he  allowed  it  to  get  up. 
The  child  was  dead  in  an  hour.  Warned  by  this,  he 
kept  the  second  child  in  bed  for  a  week  longer;  it 
was  then  allowed  to  rise.  Within  twenty-four  hours 
this  child  also  died. 


Case  VII. — A  girl  of  nearly  11  years  old  had  a 
severe  attack  of  diphtheria.  She  looked  pale  after 
this,  and  was  kept  in  bed  for  eight  weeks.  She  was 
then  allowed  to  rise.  In  five  minutes  after  rising,  she 
was  dead. 


Occurrences  of  this  kind,  so  painful  both  to  the 
surviving  relatives  and  to  the  practitioner  who  has 
given  a  hopeful  prognosis,  call  for  careful  study,  to 
see  if  we  can  detect  any  indication  which  will  warn 


SUDDEN  DEATH  AFTER  DIPHTHERIA     233 

us  of  the   coming  danger  and    enable   us    to  guard 
against  it. 

Due  to  Degeneration  of  the  Heart-Muscle. 
On  what  do  they  depend  ?  The  first  explanation 
that  suggests  itself  is  that  they  are  the  result  of  a 
neuritis  of  the  vagus,  causing  arrest  of  the  heart.  The 
paralysis  of  the  diaphragm  or  -of  the  intercostal 
muscles,  which  is  sometimes  produced  by  diphtheria, 
may  be  due  to  a  neuritis  of  the  phrenic  or  of  inter- 
costal nerves,  though  it  is  not  certain  that  this  is 
always  the  explanation.  But  before  we  assume  that 
sudden  death  after  diphtheria  is  caused  by  a  neuritis 
of  the  vagus,  we  must  remember  that  whereas  the 
action  of  the  respiratory  muscles  is  brought  about  by 
a  stimulus  from  the  respiratory  centre  in  the  medulla 
oblongata,  the  action  of  the  heart  is  maintained  by 
the  automatic  contractions  of  the  cardiac  muscle,  and 
that  it  is  by  no  means  certain  that  a  neuritis  of  the 
vagus  would  arrest  the  working  of  the  heart.  We 
must  always  bear  in  mind  that  the  cardiac  muscle 
itself  is  the  prime  factor  in  the  circulation,  and  it 
seems  likely  that  the  fatal  syncope  which  may  follow 
diphtheria  is  due  to  a  diseased  condition  of  the 
muscular  wall  of  the  heart  itself,  rather  than  to  disease 
of  the  nerves  which  pass  to  it.  The  microscope  alone 
cannot  determine  this  question,  for  when  degenera- 
tion of  muscular  fibre  is  present  it  may  be  impossible 
to  say  whether  the  toxic  action  was  exerted  on  the 


234    ACUTE  DILATATION  OF  THE  HEART,  ETC. 

nerves,  or  on  the  motor  end-plates,  or  on  the  muscle 
itself. 

That  the  muscular  wall  of  the  heart  does  undergo 
serious  degeneration  in  diphtheria,  has  been  shown 
by  several  observers.  Dr  Sidney  Martin  *  found  that 
the  diphtherial  albumoses  produced  an  advanced 
degree  of  fatty  degeneration  in  the  cardiac  muscle, 
and  he  was  unable  to  find  any  degeneration  in  the 
vagus  nerve.  Dr  Mott  f  found  fatty  degeneration  of 
the  heart-muscle  in  each  of  four  cases  of  diphtherial 
paralysis  which  he  examined,  but  in  only  one  of  them 
was  there  degeneration  of  the  peripheral  nerves.  My 
colleague,  Dr  Poynton,  if  has  recently  published  a 
comparative  study  of  the  condition  of  the  heart-wall 
in  diphtheria  and  in  rheumatism  respectively,  and  has 
described  very  marked  degeneration  of  many  of  the 
cardiac  muscular  fibres,  and  complete  destruction  of 
some  parts  of  them.  It  is  therefore  proved  that  in 
fatal  cases  of  diphtheria  the  cardiac  muscle  is  often 
much  degenerated.  The  conclusion  is  irresistible, 
that  it  must  be  more  or  less  degenerated  in  a  large 
proportion  of  the  cases  which  recover.  Can  we 
detect  any  evidence  of  this  degeneration  by  clinical 
investigation?  If  so,  fatal  cardiac  syncope  might 
be  avoided,  and  many  lives  might  be  saved  which 
would  otherwise  be  lost. 

*  Goulstonian  Lectures,  1892. 
t  Croonian  Lectures,  1900. 
I  Lancet^  12th  May  1900. 


DEGENERATION  OF  CARDIAC  MUSCLE     235 

The  clinical  indications  which  should  be  sought  for 
are  these  : 

1.  Feebleness  of  the  pulse-wave. 

2.  Feebleness  and  diffusion  of  the  cardiac  impulse. 

3.  Extension  of  the  cardiac  dullness  to  the  left. 

4.  Feebleness  of  the  first  sound  at  the  apex,  with 
accentuation  of  the  pulmonary  second  sound. 

These  four  indications  of  a  weakened  left  ventricle 
would  all  naturally  be  expected  in  a  heart  in  which 
fatty  degeneration  of  its  muscle  has  been  produced. 
They  are  all  present,  more  or  less,  in  many  cases  of 
diphtheria. 

5.  A  fifth  sign,  which  could  not  have  been  antici- 
pated, but  which  is  usually  present  also,  is  a  marked 
accentuation  of  the  aortic  second  sound.  This  is 
often  very  decided,  yet  the  radial  pulse  is  not  tense, 
and  one  can  only  imagine  that  the  tension  in  the 
aorta  is  raised  by  a  contraction  of  the  splanchnic 
arterioles  through  some  central  vaso-motor  irritation 
caused  by  the  toxins.  If  the  vascular  tension  is 
much  increased  at  the  same  time  that  the  ventricle  is 
weakened,  the  danger  of  fatal  syncope  is  obviously 


Physical  Exammatio7i  of  the  Heart. 

All  these  physical  signs  need  careful  and  accurate 
investigation.  It  is  a  matter  much  to  be  regretted 
that  the  examination  of  the  heart  is  often  very 
imperfectly  performed,  and  that  a  hasty  auscultation 


236    ACUTE  DILATATION  OF  THE  HEART,  ETC. 

— easily  satisfied  if  no  murmur  is  detected — is  in  too 
many  cases  the  only  method  employed.  But  altera- 
tions in  the  normal  sounds  of  the  heart  may  be  vastly 
more  important  than  a  murmur  ;  an  almost  inaudible 
first  sound,  or  a  greatly  exaggerated  aortic  second 
sound,  may  be  much  more  alarming.  One  must  go 
even  further,  and  say  that  the  stethoscope  has  been 
far  too  dominant  in  the  physical  examination  of  the 
heart  (and  also  of  the  lungs),  and  that  palpation  and 
percussion  are  too  much  neglected  and  often  most 
inefficiently  performed.  Especially  with  regard  to 
percussion,  the  ordinary  method  of  examination  of 
the  heart  is  quite  fallacious  and  almost  useless.  What 
is  called  the  "  superficial  cardiac  dullness  "  (often  the 
only  point  investigated  by  percussion)  informs  us 
merely  how  much  of  the  heart  is  not  covered  by  lung  ; 
it  gives  us  no  information  as  to  its  actual  size.  Yet, 
to  be  able  to  detect  this  actual  size  and  to  discover 
any  enlargement  of  the  left  ventricle  or  of  the  right 
auricle,  is  often  of  the  most  extreme  value  to  the 
practitioner,  for  a  correct  determination  of  these  is  in 
very  many  cases  a  matter  of  vital  importance  to  the 
patient. 

The  difficulty  felt  by  many  in  ascertaining  the  true 
size  of  the  heart  is  largely  caused  by  the  word  "  deep." 
The  outer  margins  of  the  heart  are  covered  by  lung, 
hence  it  has  been  thought  that  the  true  cardiac 
dullness  can  only  be  detected  by  a  forcible  percussion 
which  shall  bring  out  the  deeper  dullness  in  contrast 


PHYSICAL  EXAMINATION  237 

with  the  overlying  pulmonary  resonance.  Unfortun- 
ately this  forcible  percussion  brings  out  far  too  much 
pulmonary  and  gastric  resonance  from  a  distance,  and 
usually  confuses  the  result.  The  trained  ear  may 
sometimes  be  able  to  detect  the  change  of  note  at  the 
same  point,  whether  the  percussion  employed  be  light 
or  forcible,  but  a  light  percussion  demonstrates  the 
margin  of  the  heart  with  greatest,  certainty.  The 
edge  of  the  heart  on  either  side  is  thick  and  airless, 
while  the  overlapping  lung  is  thin,  so  that  light 
percussion  easily  reveals  the  limit  of  the  heart  to  left 
and  to  right,  as  well  as  the  smaller  area  of  its  surface 
which  is  not  covered  by  lung. 

A  finger  of  'the  left  hand  is  by  far  the  best  plexi- 
meter,  and  it  is  one  which  is  always  available.  The 
terminal  phalanx  should  be  firmly  pressed  on  the 
spot  where  percussion  is  to  be  practised,  and  the  rest 
of  the  finger  kept  away  from  the  chest-wall ;  or  the 
middle  phalanx  may  be  used  if  the  terminal  phalanx 
is  slightly  hyperextended,  so  that  both  it  and  the 
first  do  not  press  on  the  chest.  If  this  method  be 
adopted,  the  practitioner  will  have  no  difficulty,  after 
a  little  practice,  in  defining  with  very  considerable 
accuracy  the  limit  of  the  heart  both  to  left  and  to 
right.  The  limits  thus  discoverable  are  verified  by 
post-mortem  examination  in  fatal  cases. 

When  the  extent  of  the  cardiac  dullness  trans- 
versely has  been  determined  by  careful  light  per- 
cussion in  the  fourth  right,  and  the  fourth,  fifth,  and 


238    ACUTE  DILATATION  OF  THE  HEART,  ETC. 

sixth  left  intercostal  spaces,  the  position  of  the  lateral 
margins  of  the  heart  may  easily  be  defined  if  it  be 
remembered  that  they  both  slope  upwards  and 
inwards,  and  the  percussed  finger  be  held  in  a 
position  parallel  to  this  slope  in  each  case.  The  right 
margin  above  the  nipple-level  rapidly  approaches  the 
sternum  ;  but  when  the  right  auricle  is  much  dilated, 
its  dullness  may  be  detected  in  the  third  space  as  well 
as  in  the  fourth.  The  left  margin  normally  rises  to 
the  inner  side  of  the  nipple,  but  in  a  moderately 
dilated  heart  the  limit  of  dullness  will  be  found  to 
pass  through  the  nipple,  and  where  the  dilatation  is 
great  it  may  cross  the  vertical  nipple-line  at  one,  two, 
or  in  extreme  cases  even  three  fingerbreadths  above 
the  nipple.  For  further  details,  I  may  refer  to  my 
paper  on  Acute  Dilatation  of  the  Heart  in  Rheumatic 
Fever  in  the  Medico-Chirurgical  Transactions  for 
1898. 

Cardiac  Dilatation  in  Diphtheria. 

In  a  child  suffering  from  diphtheria  the  cardiac 
dullness  is  usually  increased  towards  the  left.  It  is 
very  important  to  determine  carefully  the  extent  of 
this  increase.  So  long  as  it  does  not  exceed  one 
fingerbreadth  outside  the  left  nipple-line,  there  is,  I 
think,  usually  no  immediate  danger.  But  if  the 
dullness  is  greater  than  this,  the  case  should  be  very 
carefully  watched.  If  the  dullness  extends  two 
fingerbreadths  to  the  left  of  the  nipple-line,  there  is 


RAPID  INCREASE  OF  DULLNESS  239 

urgent  peril,  and  the  child  must  not  be  allowed  to  sit 
up  in  bed  for  any  reason  whatsoever, 

I  wish  to  draw  special  attention  to  the  fact  that  the 
increase  of  dullness  is  sometimes  very  rapid :  a 
further  extension  from  one  fingerbreadth  to  two 
may  occur  within  a  few  hours.  This  acute  dilatation 
is  frequently  accompanied  by  vomiting,  and  this 
symptom  is  an  important  danger-signal.  It  has  long 
been  recognised  that  when  vomiting  occurs  in 
diphtheria  the  prognosis  is  bad,  but  I  do  not  think 
that  it  is  generally  known  that  the  vomiting  in 
this  disease  is  often  a  sign  of  an  acute  cardiac 
dilatation. 

The  symptom  may  be  due  to  other  causes,  but  in 
every  case  in  which  it  occurs,  especially  if  along  with 
it  there  is  increased  pallor  of  face  and  a  feeble  pulse, 
the  size  of  the  left  ventricle  should  be  most  carefully 
investigated  afresh,  even  though  percussion  had  been 
practised  only  a  kw  hours  previously. 

Case  VI II. — A  little  girl  under  my  care  at  the 
Hospital  for  Sick  Children,  who  had  suffered  from  a 
severe  attack  of  diphtheria  six  weeks  before,  and 
whose  cardiac  dullness  extended  one  fingerbreadth  to 
the  left  of  the  nipple-line,  was  seized  with  vomiting 
which  was  ascribed  to  some  pharyngeal  irritation. 
But  her  marked  pallor  attracted  attention  to  the 
heart,  and  it  was  found  that  the  dullness  had  within 
twenty-four  hours  increased  to  two  fingerbreadths 
outside  the  nipple-line.  By  great  care  and  watchful- 
ness her  life  was  saved.  I  have  seen  other  similar 
cases. 


240    ACUTE  DILATATION  OF  THE  HEART,  ETC. 

When  the  shock  of  the  acute  dilatation  has  passed 
off,  or  if  it  have  occurred  more  gradually,  the  patients 
may  look  and  feel  well ;  yet  their  lives  are  in  urgent 
danger.  It  is,  I  believe,  cases  of  this  kind  which 
come  to  an  unexpected  and  tragic  end.  It  is  the 
apparent  recovery,  while  the  heart  remains  enfeebled 
and  dilated,  which  misleads  the  practitioner  who  does 
not  carefully  percuss  and  palpate. 

The  cardiac  dilatation  of  diphtheria  may  occur  at 
an  early  period  of  the  illness,  even  after  only  a  few 
days.  But  a  rapid  dilatation,  or  a  rapid  increase  of 
an  earlier  dilatation,  may  take  place  even  after 
several  weeks.  In  the  case  already  narrated,  it 
occurred  six  weeks  after  the  onset.  It  is  therefore 
necessary  to  keep  a  very  careful  watch  on  the  condition 
of  a  child's  heart  for  at  least  two  months  after  a 
severe  attack  of  diphtheria. 

I  have  seen  one  case  in  which  a  permanent  dilata- 
tion of  the  heart,  apparently  the  result  of  diphtheria, 
caused  dyspnoea,  dropsy,  and  such  imminent  danger 
to  life,  that  removal  of  blood  by  leeches  was  necessary. 
But  I  doubt  whether  the  diphtherial  dilatation  is 
often  permanent ;  the  less  seriously  damaged  hearts 
probably  again  become  of  normal  size,  while  the 
worst  cases  die ;  for  the  mortality  of  "  diphtherial 
paralysis  "  is  certainly  much  greater  than  would  be 
inferred  from  the  statements  of  the  text-books.  It 
must  be  added  that  the  virulence  of  diphtheria  is 
more    intense    in    children    than    in    adults.     Herein 


RAPID  DILATATION  IN  INFLUENZA       241 

there  is  a  marked  contrast  to  the  behaviour  of  the 
disease  of  which  I  next  speak — influenza  ;  for  this  is 
often  highly  dangerous  to  adults,  while  it  affects 
children  much  less  frequently  and  usually  less 
severely. 

Cardiac  Dilatation  in  Influenza. 

In  influenza,  rapid  dilatation  of^the  heart  frequently 
occurs,  to  a  greater  or  less  extent,  within  a  day  or 
two  after  the  onset  of  the  disease,  and  it  sometimes 
causes  fatal  syncope.  If  the  heart  be  carefully 
examined,  it  will  often,  though  not  in  all  cases,  be 
found  distinctly  enlarged  towards  the  left,  the  impulse 
diffused  and  weakened,  the  first  sound  feeble,  and  the 
pulse  wave  also  feeble.  Here  again,  as  in  diphtheria, 
if  the  increase  of  dullness  does  not  exceed  one  finger- 
breadth  to  the  left  of  the  nipple-line,  there  is  probably 
little  danger.  But  if  there  is  a  second  fingerbreadth 
of  dullness,  there  is  real  danger.  And  in  this  disease 
also  the  extension  of  dullness  may  develop  rapidly. 

Case  IX. — In  one  of  the  first  years  of  the  influenza 
epidemic,  a  young  man  was  admitted  into  St  Mary's 
Hospital  under  my  care,  suffering  from  influenza,  and 
obviously  very  ill,  with  some  evidence  of  pleurisy,  but 
none  of  pneumonia.  The  cardiac  dullness  extended 
as  far  as  one  fingerbreadth  outside  the  nipple-line. 
Fearing  possible  syncope,  I  asked  the  house-physician 
to  direct  the  night-sister  to  give  a  hypodermic  injection 
of  strychnine  immediately  if  the  patient  were  taken 
ill  during  the  night.  A  few  hours  after  I  saw  him,  an 
attack    of  syncope    occurred.       The    strychnine    was 

Q 


242    ACUTE  DILATATION  OF  THE  HEART,  ETC. 

administered  and  the  house-physician  sent  for.  On 
examining  the  patient,  he  found  that  the  dullness  of 
the  left  ventricle  now  extended  two  fingerbreadths 
outside  the  nipple-line.  This  I  myself  found  to  be 
the  case  the  next  day.  Forty-eight  hours  after  the 
first  attack  of  syncope,  a  second  occurred  ;  the  house 
physician  found  that  the  dullness  now  extended  to 
three  fingerbreadths  to  the  left  of  the  nipple-line. 
Half  an  hour  later  he  was  again  summoned,  and 
found  the  patient  dead. 

Whether  acute  dilatation  may  occur  some  weeks 
after  the  onset,  as  in  diphtheria,  I  do  not  know ;  but 
it  is  not  unlikely,  for  many  of  the  sequelae  of  influenza 
do  not  manifest  themselves  until  weeks  or  even 
months  after  the  attack,  and  it  is  quite  possible  that 
an  extra  cardiac  failure  may  be  one  of  these.  It  is 
certain  that  the  dilatation  caused  by  influenza  may 
remain  as  a  permanent  dilatation,  and  may  give  rise 
to  very  serious  symptoms.  Thrombosis  is  also  of 
frequent  occurrence  after  influenza,  probably  due  in 
part  at  least  to  the  enfeeblement  of  the  heart.  This 
thrombosis  may  in  its  turn  produce  pulmonary  em- 
bolisms, resulting  in  great  dyspnoea  and  haemoptysis, 
or  even  in  sudden  death  from  obstruction  of  the  pul- 
monary artery. 

Minor  degrees  of  cardiac  dilatation  after  influenza 
may  cause  merely  a  feeling  of  incapacity  for  exertion. 
Unless  the  size  and  strength  of  the  left  ventricle  be 
carefully  ascertained,  such  a  patient  may  be  considered 
a  hypochondriac,  and  very  injudicious  advice  may  be 


ACUTE  DILATATION  IN  RHEUMATISM     243 

given  to  him.  Active  exertion,  unless  carefully  con- 
trolled, may  do  such  a  patient  much  harm  by  in- 
creasing the  dilatation.  Any  prolonged  strain — for 
instance,  the  effort  of  cycling  uphill — may  be  very 
injurious  after  an  attack  of  influenza. 

Case  X. — Some  years  ago,  I  was  asked  to  see  a 
young  lady  whose  only  complaint  was  that  she  felt 
languid  and  incapable  of  exertion.  'She  had  suffered 
from  influenza  some  months  before.  She  was  very  fond 
of  cycling,  and  had  acted  as  the  "  hare  "  in  games  of 
"  hare  and  hounds "  by  cyclists.  Her  left  ventricle 
extended  to  two  fingerbreadths  outside  the  nipple- 
line.  There  was  no  murmur.  By  careful  regulation 
of  her  exercise  she  recovered  completely,  and  the 
limit  of  the  cardiac  dullness  is  now  well  inside  the 
nipple-line. 

Cardiac  Dilatation  in  Rheumatic  Fever. 

In  rheumatic  fever,  even  in  the  most  subacute 
attacks,  acute  dilatation  of  the  heart  seems  to  be 
invariably  present.  Since  I  first  observed  its  occur- 
rence, in  1894,  I  have  never  seen  a  first  attack  of  this 
disease,  whether  in  a  child  or  in  an  adult,  in  which  it 
was  absent.  When  the  rheumatic  attack  is  over,  the 
dilatation  lessens  and  the  cardiac  dullness  may  again 
become  of  normal  extent.  It  may  be  well  to  quote  a 
recent  case  in  illustration  of  this  : 

Case  XI. — A  woman  of  28,  who  had  never  pre- 
viously suffered  from  rheumatism,  was  admitted  into 
St  Mary's  Hospital  under  my  care  on  29th  May  1900, 


244    ACUTE  DILATATION  OF  THE  HEART,  ETC. 

on  account  of  some  pain  in  her  limbs,  of  five  days' 
duration,  with  slight  swelling  of  both  knees  and  of 
one  ankle,  and  some  oedema  of  the  legs.  The  tempera- 
ture was  loi''  F.  There  was  no  murmur,  but  the 
cardiac  dullness  extended  two  and  a  half  fingerbreadths 
outside  the  left  nipple-line.  The  house-physician  pre- 
scribed potassium  citrate  with  caffeine  and  strychnine, 
but  no  salicylates.  After  twenty-four  hours  the 
rheumatic  symptoms  were  worse,  and  the  dullness 
had  increased  to  three  fingerbreadths  to  the  left  of 
the  nipple-line.  The  medicine  was  then  changed  to 
sodium  salicylate  and  bicarbonate.  Within  thirty-six 
hours  the  temperature  had  fallen  to  normal,  and  it 
remained  normal.  On  5th  June — five  days  after  the 
change  of  medicine — the  left  limit  of  the  cardiac 
dullness  was  only  one  fingerbreadth  and  a  half  outside 
the  left  nipple-line.  On  12th  June  it  extended  only 
one  half  fingerbreadth  to  the  left  of  the  nipple,  and 
on  15th  June  the  border  of  the  dullness  was  in  the 
nipple-line  itself  On  her  discharge  from  the  hospital 
the  cardiac  dullness  and  sounds  were  normal. 

In  this  instance  the  rheumatic  dilatation  was  un- 
usually great  for  a  first  attack,  and  the  cardiac  weak- 
ness had  produced  some  oedema  of  the  legs,  which  is 
also  unusual  in  a  first  and  apparently  slight  attack  of 
rheumatism.  The  latter  symptom  disappeared  after 
three  days'  rest  in  bed,  and  coincidently  with  a 
marked  improvement  in  the  rheumatic  symptoms 
and  with  the  fall  of  temperature.  Both  the  oedema 
and  the  considerable  increase  of  cardiac  dullness 
indicated  a  severe  implication  of  the  cardiac  muscle, 
yet  there  was  no  evidence  of  endocarditis  or  peri- 
carditis. 


LESS  DANGEROUS  THAN  IN  DIPHTHERIA  245 

In  later  attacks  also  an  acute  dilatation  is  usually 
present,  for  it  may  almost  always  be  observed,  on 
careful  examination,  that  the  dullness  of  the  left 
ventricle  diminishes  to  some  extent — greater  or  less 
— as  the  attack  subsides.  At  all  events,  one  may  say 
with  certainty  that  an  acute  dilatation  of  the  heart  is 
much  more  common  in  rheumatism,  even  in  slight 
attacks,  than  in  either  diphtheria  of  influenza.  Yet, 
though  more  common,  it  is  far  less  dangerous.  I 
have  already  said  that  an  extension  of  the  cardiac 
dullness  to  two  fingerbreadths  outside  the  left  nipple- 
line  is  an  indication  of  grave  danger  in  a  child  affected 
with  diphtheria.  I  will  now  add  that  the  same  amount 
of  increased  dullness  in  a  child  suffering  from  rheu- 
matism implies,  in  itself,  no  immediate  danger  of 
death  whatever. 

It  is  a  very  remarkable  fact  that  the  dilatation  of 
rheumatism  is  so  much  less  dangerous  than  that  of 
diphtheria  or  of  influenza,  in  spite  of  its  greater 
frequency  in  considerable  amount.  The  difference 
must  be  produced  by  a  different  effect  of  the  several 
toxins  upon  the  cardiac  muscle.  In  diphtheria,  and 
apparently  in  influenza,  the  muscular  fibres  of  the 
left  ventricle  suffer  greater  destruction ;  in  rheumatism, 
the  myocardial  changes  are  less  intense,  and  one  can 
only  suppose  that  the  elasticity  of  the  ventricle  is 
more  affected.  Dr  Poynton's  sections  show  that, 
though  in  the  rheumatic  heart  there  is  evidence  of 
fatty  degeneration  of  the  cardiac  muscular  fibres,  with 


246    ACUTE  DILATATION  OF  THE  HEART,  ETC. 

interstitial  foci  of  small  cells  and  vascular  dilatation, 
yet  the  destruction  of  muscle  is  much  less  pronounced 
than  in  the  diphtherial  heart. 

But  though,  as  I  have  said,  an  increase  of  cardiac 
dullness  to  two  fingerbreadths  outside  the  nipple-line 
in  a  case  of  rheumatism  involves  no  danger  of  sudden 
death,  yet  a  further  extension,  occurring  rapidly,  may 
cause  decided  symptoms  of  collapse.  Here  again,  as 
in  diphtheria,  a  sudden  vomiting  is  often  the  danger 
signal.  Pallor,  coldness,  and  general  feebleness 
follow,  and  the  cardiac  dullness  is  found  to  have 
increased  by  an  additional  fingerbreadth  within  a  few 
days  or  even  within  a  few  hours.  From  two  finger- 
breadths  outside  the  nipple  it  increases  to  three,  or 
from  three  it  may  extend  to  four  ;  at  the  same  time 
the  border  of  the  left  ventricle  reaches  a  greater 
height  above  the  nipple,  from  one  to  two  finger- 
breadths,  or  from  two  to  three.  The  cardiac  impulse 
becomes  more  diffused  and  much  weaker.  Mitral 
valvulitis  will  almost  certainly  be  present,  causing  a 
systolic  murmur  at  the  apex,  and  very  frequently  a 
presystolic  murmur  is  present  also.  There  may  be 
in  addition  evidence  of  pericarditis  or  of  pericardial 
adhesion.  The  implication  of  the  mitral  valve,  allow- 
ing regurgitation  into  and  therefore  increased  tension 
within  the  auricle,  has  doubtless  some  share  in  the 
great  enlargement  of  the  left  ventricle  which  may 
occur  in  the  later  stages  of  rheumatism  in  a  child. 
But  the  damaged  condition  of  the  cardiac  muscle  is 


EASILY  OVERLOOKED  247 

certainly  the  chief  cause,  and  such  cases  should  not 
be  looked  upon  as  simply  "  mitral  regurgitation."  In 
children  the  dilatation  is  of  much  greater  importance 
than  the  valvular  lesions.  But  it  may  easily  escape 
the  notice  of  a  practitioner  Vv^ho  does  not  constantly 
practise  a  careful  examination  of  the  heart  by  palpa- 
tion and  percussion,  for  it  is  very  remarkable  how 
slight  may  be  the  superficial  evidence  of  a  rheumatic 
toxaemia,  which  yet  is  able  to  produce  a  perceptible 
enlargement  of  the  heart. 

Case  XII. — A  little  girl  under  my  care,  who  was 
convalescent  from  a  rheumatic  attack  which  had 
dilated  her  left  ventricle  to  two  fingerbreadths  out- 
side the  nippFe-line,  was  found  one  day  to  have  some 
bronchial  catarrh,  with  slight  pain  in  her  left  ankle, 
and  a  new  small  nodule  over  this  joint  On  my  next 
visit  to  the  ward,  I  was  struck  with  her  pallor  and 
evident  illness ;  the  ankle  was  better,  but  the  left 
ventricle  was  now  dilated  to  three  fingerbreadths 
instead  of  two. 

Case  XIII. — In  another  child,  the  only  obvious 
indication  of  a  rheumatism  which  perceptibly  enlarged 
his  left  ventricle  was  a  very  slight  and  transitory  patch 
of  erythema  on  his  neck. 

The  slightest  suspicion  of  rheumatism  in  a  child 
should  therefore  lead  to  careful  and  repeated  examina- 
tion of  the  heart.  Even  in  adults,  much  oftener  than 
is  generally  recognised,  it  is  fresh  rheumatism  that 
kills,  breaking  down  compensation.  It  is  important 
to  notice  that  at  the  necropsy  of  patients  who  have 


248    ACUTE  DILATATION  OF  THE  HEART,  ETC. 

died  from  chronic  rheumatic  heart-disease,  there  is 
usually  evidence  of  fresh  endocarditis  on  the  cardiac 
valves.  And,  clinically,  it  may  often  be  observed  that 
when  a  case  of  mitral  stenosis  breaks  down  there  is 
some  evidence  of  fresh  rheumatism. 

Case  XIV. — A  woman  recently  under  my  care  at 
St  Mary's  Hospital  exemplified  this.  She  was  mori- 
bund on  admission,  and  was  found  to  have  mitral 
stenosis,  a  much  dilated  heart,  and  thrombosis  of  the 
right  jugular  vein.  It  was  thought  by  all  who  saw 
her  that  she  would  not  live  more  than  a  day  or  two. 
Venesection  three  times  repeated,  once  from  each 
arm  and  once  from  the  left  jugular,  saved  her  from 
the  immediate  danger  ;  the  thrombosis  did  not  extend, 
and  she  improved  so  much  that  she  begged  to  be 
allowed  to  go  home  to  look  after  her  children.  But 
during  the  five  weeks  that  she  lived  after  her  admis- 
sion there  was  persistent  recurrence  of  a  slight  rheu- 
matic arthritis  in  the  joints  of  her  hands — an  arthritis 
which  at  once  yielded  to  salicylates,  but  regularly 
returned  when  the  medicine  was  omitted.  At  the 
necropsy  evidence  of  fresh  endocarditis  was  found,  in 
addition  to  the  mitral  stenosis. 

I  have  now  shown  that  diphtheria,  influenza,  and 
rheumatic  fever  are  all,  in  various  measures,  associ- 
ated with  acute  dilatation  of  the  heart.  In  fatal  cases 
of  diphtheria  and  of  rheumatism,  myocarditis  and 
fatty  degeneration,  or  even  destruction,  of  cardiac 
muscle  are  often  found ;  probably  similar  lesions 
exist  in  influenza. 

Now,  it  cannot  be  questioned  that  in  diphtheria  and 


THE  DIPLOCOCCUS  OF  RHEUMATISM      249 

in  influenza  the  injury  to  the  heart  is  caused  by  the 
deleterious  action  of  the  toxin  produced  by  a  microbe. 
In  each  of  these  two  diseases  the  microbe  is  well 
known.  Is  it  not,  then,  in  the  highest  degree  probable 
that  rheumatic  fever  also  is  a  microbic  disease,  and 
that  the  resultiug  cardiac  inflammation  is  due  to  its 
toxin  ?  A  study  of  rheumatism  in  childhood  compels 
me  to  say  that  it  is  as  certainly  mix:roiDic  in  nature  as 
measles  or  whooping-cough,  in  neither  of  which  the 
microbe  has  yet  been  demonstrated. 

But  it  is  no  longer  a  matter  of  inference  merely 
that  rheumatic  fever  is  a  microbic  disease,  for  it  has 
been  proved  by  Dr  Poynton  and  Dr  Paine  of  St 
Mary's  Hospital*  that  a  diplococcus  can  be  isolated 
from  the  tissues  of  a  patient  who  has  died  from  rheu- 
matic fever,  and  also  from  blood  obtained  by  vene- 
section during  life,  which  can  be  cultivated  in  pure 
culture  in  a  suitable  medium,  and  which,  when  injected 
intravenously  into  rabbits,  can  produce  in  them  a 
transitory  arthritis  of  several  joints,  tenosynovitis, 
pericarditis,  valvulitis,  cardiac  degeneration  and  dilata- 
tion, pleurisy  and  pneumonia,  and  yet  nowhere  any 
suppuration.  By  careful  staining  of  their  sections, 
they  have  succeeded  in  demonstrating  these  organisms 
in  the  substance  of  the  mitral  valve,  in  the  tonsils, 
and  in  many  other  organs.  They  have  found  them 
also  in  that  most  typically  rheumatic  lesion,  the  sub- 
cutaneous nodule.  Their  results  will,  of  course, 
*  Lancet^  22nd  and  29th  September  1900. 


250    ACUTE  DILATATION  OF  THE  HEART,  ETC. 

require  confirmation  by  other  observers,  but  it 
certainly  seems  that  the  problem  of  acute  rheuma- 
tism has  at  last  been  solved. 

Importance  of  tJie  Diagnosis  of  Cardiac  Dilatation. 
Finally,  let  me  appeal  for  greater  care  and  accuracy 
in  the  examination  of  the  heart  by  percussion  and 
palpation.  It  is  a  matter  of  great  importance  to  the 
patient.  Dilatation  and  feebleness  of  the  left  ventricle 
may  indicate,  as  I  have  shown,  urgent  danger  of  death 
from  syncope,  and  neglect  of  this  indication  may  cost 
the  patient's  life.  Dilatation  of  the  right  auricle 
(quite  easily  detected  by  percussion  in  the  fourth 
right  interspace),  and  weakness  of  the  right  ventricle 
(detected  by  palpation  of  the  epigastric  region)  are 
usually  accompanied  by  considerable  dyspnoea  and 
often  by  some  lividity.  A  marked  degree  of  dilatation 
of  the  right  auricle  (from  two  to  three  fingerbreadths 
to  the  right  of  the  sternal  margin  in  the  fourth  space) 
may  indicate  grave  danger  of  death  from  asphyxia 
and  call  urgently  for  venesection  or  leeches. 

After  a  considerable  experience  as  an  Examiner  in 
Medicine,  I  am  forced  to  the  conclusion  that  these 
facts  are  still  very  inadequately  recognised,  for  I 
rarely  meet  with  a  candidate  who  understands  the 
object  of  percussion  of  the  heart  or  the  proper  method 
of  procedure.  He  usually  thinks  only  of  the  useless 
"  superficial  cardiac  dullness,"  and  contents  himself 
with   trying   to  determine   a   horizontal    upper    limit 


IMPORTANCE  OF  CAREFUL  EXAMINATION    251 

(which  does  not  exist),  and  then  palpating  the  cardiac 
impulse,  as  if  that  were  equivalent  to  the  left  border 
of  the  dullness  !  The  right  limit  of  the  heart  he  usually 
neglects  altogether.  And  even  some  physicians  of 
great  eminence  are  apparently  not  conversant  with 
the  fact  that  the  dullness  of  the  right  auricle  normally 
extends  one  fingerbreadth  into  the  fourth  right  space, 
and  that  its  border  can  be  quite -easily  detected  by 
careful  light  percussion. 

Let  me  assure  you  that  there  is  really  very 
little  difficulty  in  the  determination  of  the  actual 
size  of  the  heart,  and  that  a  small  amount  of  careful 
practice  will  demonstrate  to  you  what  an  enormous 
advantage  both  to  your  patients  and  to  yourselves 
will  result  if  you  will  accustom  yourselves  to  consider 
this  as  an  essential  part  of  the  investigation  of  every 
case  to  which  you  are  called.    ' 


A  PRESIDENTIAL  ADDRESS  ON  THE 
HEART  OF  THE  CHILD. 

{Delivered  before  the  Harveian  Society^  1902.) 

The  laws  of  the  Harveian  Society  of  London  require 
that  at  the  conclusion  of  his  year  of  office  the 
President  shall  deliver  an  address.  I  ask  your  atten- 
tion, therefore,  for  a  few  moments  to  a  short  study 
of  a  subject  too  much  neglected — the  heart  of  the 
child. 

"  The  child's  heart,"  said  Dr  Sturges,  in  the  Lum- 
leian  Lectures  for  1894,*  "holds  ^s  many  secrets  as 
the  man's,  and  is  even  more  deceiving."  If  this  be  so, 
it  needs  the  more  careful  study,  and  (even  more  than 
the  heart  of  the  adult)  demands  accurate  investigation 
and  patient  observation.  Yet  who  thinks  it  worth 
while  to  spend  much  time  in  examining  the  heart  of  a 
child  ?  Does  every  medical  man  investigate  the  con- 
dition of  this  organ  in  each  child-patient  as  carefully 
as  he  does  in  an  adult?  In  how  many  instances  does 
he  even  recognise  that  it  is  his  duty  to  examine  it  ? 
*  The  Lancet^  1894. 

252 


THE  WORK  OF  THE  HEART  253 

Doubtless  he  feels  the  child's  pulse,  but  does  he  bestow 
much  care  upon  the  investigation  of  the  heart  itself? 
Does  he  always  remember  that  heart  -  disease  is 
frequent  in  early  life,  that  its  beginnings  may  easily  be 
overlooked  unless  he  is  careful,  and  that  his  neglect 
to  ascertain  the  exact  condition  may  be  disastrous  to 
the  whole  of  the  child's  future  ?  Think  of  the  amount 
of  work  which  the  child's  heart  will  have  to  undertake. 
Calculating  at  the  rate  of  one  beat  per  second,  which 
is  below  the  truth,  it  will  have  to  contract  no  less  than 
31,536,000  times  every  year.  If  it  survive  for  50  years 
it  will  have  performed  the  enormous  number  of 
1576  millions  of  beats.  And  if  we  adopt  the  estimate 
of  Dr  Leonard  Hill  in  the  second  volume  of  Schafer's 
Physiology^  that  the  human  heart  performs  work  to 
the  amount  of  1000  kilogrammetres  every  hour,  we 
find  that  in  a  year  its  total  work  will  be  8,760,000 
kilogrammetres,  and  in  50  years  438,000,000  kilo- 
grammetres. Translating  this  into  English  measures 
we  find  that  during  these  50  years  the  heart  will 
have  to  lift  1,500,000  tons  to  a  height  of  one  foot. 
That  is  the  work  which  lies  before  the  child's  heart  if 
it  survive  through  a  life  of  50  years.  How  can  it 
possibly  accomplish  the  task  unless  it  is  thoroughly 
sound  and  well  ?  Remember,  also,  that  the  child's 
heart  is  an  organ  incompletely  developed.  It  has  to 
grow  to  its  full  size  and  to  minister  to  a  growing  body. 
Any  disease,  therefore,  which  damages  it  not  only 
hinders  its  future  work  but  impedes  its  development 


254  THE  HEART  OF  THE  CHILD 

and  the  development  of  the  whole  organism.  From 
this  point  of  view,  the  integrity  of  the  child's  heart  is 
even  more  important  than  that  of  the  man's. 

The  child's  heart  can  be  examined  by  the  same 
methods  as  are  employed  for  that  of  an  adult.  In 
some  respects  it  is  even  more  accessible,  for  in  the 
child  there  is  no  excess  of  adipose  tissue,  no  great 
muscular  development,  no  large  pendulous  breasts, 
and  rarely  any  emphysema.  If  the  practitioner  is 
rough  and  awkward,  he  may  make  difficulties  for  him- 
self by  exciting  the  child's  fears,  but  anyone  who 
knows  how  to  deal  with  children  can  usually  examine 
the  heart  of  even  the  most  "  spoiled "  child  with 
accuracy.  Impatient  words,  an  ungenial  aspect,  rough 
manipulation,  or  cold  hands,  may  make  a  young  child 
cry  and  resist  with  all  its  might ;  but  pleasant  speech, 
a  kindly  manner,  gentle  ways,  and  warm  hands  will 
usually  calm  the  most  nervous  child  and  allow  of  a  com- 
plete examination,  provided  that  the  undressing  is  done 
by  the  mother  or  the  nurse,  and  that  she  stands  by  the 
bed  while  the  examination  is  made. 

The  chest  being  thus  exposed  to  view,  we  notice  at 
once  whether  there  is  any  thoracic  deformity  or  any 
prominence  of  the  precordial  region,  and  the  position 
of  any  visible  cardiac  impulse.  Having  noted  this,  the 
first  idea  of  most  practitioners  is  to  pull  out  a  ter- 
rible looking  instrument  called  a  stethoscope,  which 
probably  appears  to  the  child  a  sort  of  pistol,  and 
doubtless  is  going  to  hurt  him  not  a  little.     This  early 


METHOD  OF  EXAMINATION  1^55 

recourse  to  the  stethoscope  is  a  great  mistake  for  more 
reasons  than  one.  Keep  it  in  your  pocket  to  the  last. 
A  child  is  accustomed  to  being  handled  ;  you  may  use 
your  hands  to  examine  him  as  much  as  you  like  if 
they  are  only  warm  and  gentle.  He  will  not  object 
at  all  to  percussion  if  it  be  done  very  lightly  and  with 
the  fingers  only,  but  he  will  not  tolerate  the  forcible 
hammering  which  some  medical  men  call  percussion, 
and  those  illusory  instruments  known  as  pleximeters 
will  certainly  make  him  cry.  Fortunately,  what  the 
child  allows  is  exactly  what  the  physician  ought  to 
use,  the  lightest  possible  percussion.  It  is  this,  and  not 
the  heavy  thumping,  which  is  to  tell  you  the  precise 
size  of  his  heart.  But  first  warm  your  hand  and  lay 
it  gently  over  the  precordial  region,  that  you  may  feel 
the  cardiac  impulse  and  ascertain  its  strength,  and 
whether  it  is  localised  or  diffused.  This  gives  you  in- 
formation as  to  the  strength  of  the  left  ventricle. 
Then  shift  your  hand  gently  to  the  epigastrium,  and 
notice  whether  any  impulse  of  the  right  ventricle  is  to 
be  felt  there ;  if  so,  either  there  is  some  congenital 
malformation  or  there  is  some  disease  of  the  lungs  or 
left  heart.  Slide  the  hand  further  to  the  hepatic 
region  and  see  whether  it  meets  the  resistance  of  an 
enlarged  liver,  and  try  very  gently  to  feel  its  edge. 
A  single  gentle  tap  on  a  finger  below  the  costal 
margin  will  confirm  or  correct  your  observation. 

Next  proceed  to  percussion,  but  begin  with  a  clear 
idea  of  the  object  of  this  measure,  and  the  way  in 


256  THE  HEART  OF  THE  CHILD 

which  it  is  to  be  carried  out.  What  is  the  object  of 
percussion  of  the  heart  ?  To  ascertain  the  superficial 
cardiac  dullness,  say  the  text-books.  But  what  is  the 
value  of  this  result  when  you  have  obtained  it? 
Almost  nothing,  from  the  cardiac  point  of  view, 
though  it  may  give  valuable  information  about  the 
left  lung.  What  we  really  want  to  know  and  what 
can  quite  easily  be  ascertained  is  the  exact  size  of  the 
heart.  We  can,  indeed,  determine  little  or  nothing 
by  physical  examination  about  the  size  of  the  left 
auricle,  and  we  can  form  only  an  approximate  opinion 
of  the  size  of  the  right  ventricle.  But  the  size  of  the 
left  ventricle  and  that  of  the  right  auricle  can  usually 
be  ascertained  with  very  considerable  accuracy.  Let 
your  pleximeter  be  the  terminal  phalanx  of  a  finger 
of  your  left  hand.  Let  this  phalanx  be  pressed 
somewhat  firmly,  yet  very  gently,  on  the  spot  to  be 
percussed,  and  let  no  other  part  of  your  hand  touch 
the  chest-wall.  Thus  you  will  avoid  the  conduction 
of  resonance  from  elsewhere  which  is  a  fruitful  source 
of  fallacy.  First  select  a  spot  in  the  mid-axilla  and 
percuss  here  with  the  lightest  possible  stroke ;  then 
gradually  shift  your  percussed  finger  towards  the 
sternum  and  you  will  easily  recognise  the  change  of 
note  when  the  border  of  the  heart  is  reached.  For 
though  the  left  lung  partly  overlaps  the  heart  it  is 
only  by  a  thin  layer,  and  the  margin  of  the  heart  is 
thick  and  airless  and  does  not  require  what  is  called 
"  deep"  or  heavy  percussion  to  recognise  it.     Indeed, 


THE  SIZE  OF  THE  HEART  257 

such  percussion  often  defeats  itself,  for  it  introduces 
pulmonary  and  gastric  resonance  from  a  distance, 
especially  if  the  whole  of  the  percussed  finger  be 
applied  to  the  chest-wall.  Expect  to  find  the  cardiac 
margin  a  little  to  the  left  of  the  position  of  the 
impulse,  for  though  it  is  usual  to  speak  of  the  "  apex- 
beat,"  it  is  not  the  extremity  of  the  heart  which 
strikes  the  chest-wall,  but  a  spot  on_the  right  ventricle 
at  some  little  distance  from  that  extremity.  The  left 
border  of  the  cardiac  dullness  in  health  extends  a 
little  to  the  left  of  the  position  of  the  impulse  ;  when 
the  heart  is  dilated,  this  difference  may  amount  to  a 
fingerbreadth  or  even  more.  (If  anyone  objects  to 
the  term  "  fingerbreadth  "  as  unscientific,  he  may  say 
instead  "  2  centimetres " ;  but  he  does  not  thereby 
make  the  measure  more  accurate,  he  only  introduces 
a  false  idea  of  mathematical  precision.)  Next  deter- 
mine whether  the  dullness  extends  to  the  left  of  the 
nipple  itself,  and  if  so  to  what  amount  in  the  nipple- 
acromial  line.  Two  points  on  the  border  of  the  left 
ventricle  having  been  thus  determined,  the  line  con- 
necting them  should  correspond  to  this  border,  and 
this  can  easily  be  verified  by  holding  the  percussed 
finger  parallel  to  this  line..  The  difference  in  tone  to 
the  left  and  to  the  right  of  this  line  will  then  be 
obvious  at  once.  Next  determine  the  size  of  the 
right  auricle.  Very  few  percussors  pay  the  least 
attention  to  this  structure,  and  many  seem  to  be 
unaware  of  the  fact  that  the  dullness  due  to  it  may 

R 


258  THE  HEART  OF  THE  CHILD 

always  be  detected,  even  in  the  normal  heart,  in 
the  fourth  right  intercostal  space.  The  third  space 
ought  to  be  resonant  quite  up  to  the  sternum,  and  in 
the  fifth  space  the  hepatic  dullness  alters  the  note, 
but  in  the  fourth  space  the  dullness  of  the  right 
auricle  is  present  for  about  one  fingerbreadth  in  an 
adult  and  rather  less  in  the  child.  When  the  auricle 
is  dilated,  it  may  extend  to  two  fingerbreadths  in  the 
fourth  space,  and  from  a  half  to  one  fingerbreadth  in 
the  third.  When  the  dilatation  is  very  great,  it  may 
amount  to  three  fingerbreadths  in  the  fourth  space, 
one  and  a  half  in  the  third,  and  may  even  be  detected 
in  the  second.  The  accurate  determination  of  the 
size  of  the  right  auricle  is  a  matter  of  the  greatest 
importance  and  often  indicates  at  once  the  necessity 
for  leeches  to  relieve  distension.  Yet  there  is  no 
part  of  physical  examination  which  is  so  universally 
and  systematically  neglected,  and  the  patient  is  too 
often  allowed  to  suffer  cardiac  distress  when  he  might 
be  relieved  in  a  few  minutes.  The  suffering  due  to  a 
distended  bladder  a  medical  man  would  promptly 
relieve,  but  that  due  to  a  distended  right  heart  is 
allowed  to  remain,  because  his  percussion  is  not 
accurate  and  bleeding  is  out  of  fashion.  Recently, 
when  I  advised  a  practitioner  in  charge  of  a  case  of 
pneumonia  to  try  the  effect  of  a  few  leeches,  he  replied 
that  he  would  "  see  if  they  could  be  obtained  in  the 
neighbourhood."  Evidently  the  distended  right  hearts 
of  this  gentleman's  patients  got  no  relief 


AUSCULTATION  259 

You  have  now  determined  the  most  important 
facts  about  the  heart,  its  size  and  strength,  and  your 
stethoscope  is  still  in  your  pocket.  But  by  this  time 
you  and  the  child  are  on  good  terms,  and  you  may 
quietly  produce  it  without  alarming  him.  It  should 
be  flexible  and  binaural ;  the  rigidity  of  the  old 
wooden  instrument  makes  its  use  difficult  in  the  child, 
and  you  are  apt  to  press  too  heavily  with  it.  Avoid  the 
cumbersome  instruments  with  a  spring ;  all  that  you 
want  is  a  small  and  simple  ivory  cup  as  a  chest-piece, 
with  two  rubber  tubes  from  it  to  two  ivory  ear-pieces. 
If  these  fit  the  ears  properly,  there  is  no  need  for  any 
spring.  This  more  simple  instrument  is  better  for 
your  purpose,  for  it  makes  no  artificial  noises  of  its 
own  and  it  is  less  alarming  to  the  child.  If  the  latter 
shows  any  sign  of  fear,  it  may  be  well  to  let  him  have 
it  in  his  hands  for  a  minute  or  two  and  look  upon  it 
as  a  new  kind  of  toy  before  he  is  made  the  subject  of 
its  scientific  application. 

In  auscultating  the  heart  of  a  child,  be  on  the  look- 
out for  murmurs  due  to  congenital  malformation. 
Very  peculiar  some  of  them  are,  and  sometimes  very 
puzzling.  The  most  frequent,  1  think,  is  a  systolic 
murmur,  often  very  loud,  which  is  loudest  at,  or  just 
below,  the  junction  of  the  left  fourth  costal  cartilage 
with  the  sternum  ;  it  is  probably  often  due  to  an 
incomplete  cardiac  septum.  The  next  most  common, 
perhaps,  is  a  systolic  murmur  over  the  pulmonary 
artery,  loudest  at  the  second  left  cartilage  and  con- 


260  THE  HEART  OF  THE  CHILD 

ducted  towards  the  clavicle,  often  audible  in  one  or 
both  supra-scapular  fossae.    This  indicates  a  congenital 
obstruction   of  the   pulmonary   artery.      It   is   often 
impossible  to  diagnose  the  exact  condition  of  a  mal- 
formed heart  by  physical  examination,  and  in  some 
cases  there   may  be   no    murmur   at  all.     A   patent 
foramen  ovale,  unassociated  with  any  other  malforma- 
tion, is  probably  of  little  importance,  and  is  a  doubtful 
cause  of  murmur.     Congenital  murmurs  are  systolic 
in  time ;  a  presystolic  or  diastolic  congenital  murmur 
is  exceedingly  rare.     Congenital  malformations  of  the 
heart   mainly   affect   its    right   side,   which   has    the 
predominance    in    activity   during   intra-uterine  life. 
After  birth   this   side   has    much   less  proneness   to 
disease  than  the  left,  though  the  tricuspid  valve  does 
not  always  entirely  escape  in  rheumatism.     But  the 
most  important  affection  of  the  right  heart  clinically 
is  secondary  to  acute  or  extensive  chronic  disease  of 
the  lungs  or  to  disease  of  the  left  heart.     In  all  such 
conditions  a  careful  watch  should   be   kept   on   the 
amount  of  distension  of  the  right  auricle.     Think  of 
the   tremendous   strain  on   the   right  heart  which  a 
pneumonia  causes   even  within  two  or   three  days. 
The  thin-walled   auricle  becomes  greatly  distended, 
and  the  stronger  ventricle  shares  to  a  less  extent  in 
the   distension.       If  the   auricle   did    not   act    as    a 
reservoir,  the  ventricle  would  soon  be  over-distended 
and  its  action   brought   to   a   standstill.      To  .some 
extent,  then,  the  dilatation  of  the  auricle  is  conserva- 


DILATATION  OF  RIGHT  HEART  261 

tive,  but  if  it  exceed  a  certain  amount  the  border-line 
which  separates  safety  from  danger,  is  easily  crossed. 
Distress  and  dyspnoea  are  experienced,  and  the  right 
ventricle  has  greater  and  greater  difficulty  in  expelling 
its  blood.  If  at  the  same  time  its  muscular  structure 
is  poisoned  by  pneumococcal  toxins,  we  can  easily 
understand  that,  even  in  a  child  with  healthy  heart, 
liver,  and  kidneys,  a  pneumonia  is-  a  process  danger- 
ous to  life.  It  is  true  that  the  child  has  a  much  better 
chance  than  the  adult  of  weathering  the  storm,  yet  its 
violence  may  be  much  diminished  and  the  patient 
often  very  obviously  relieved  by  applying  a  few 
leeches  over  his  liver.  Not  only  are  the  distress 
and  dyspnoea  diminished,  but  the  patient  is  enabled 
to  sleep.  When  the  right  heart  is  over-distended, 
sleep  is  much  disturbed  and  may  be  impossible. 
Relieve  the  over-distension  by  a  few  leeches,  and  the 
patient  falls  asleep  without  any  hypnotics.  Within  a 
short  time  after  the  bleeding  you  will  find  on  careful 
percussion  that  the  dullness  in  the  fourth  right  space 
has  diminished,  often  by  as  much  as  a  fingerbreadth. 
The  relief  will  almost  certainly  last  for  two  days, 
perhaps  longer.  But  do  not  forget  to  percuss  out 
the  auricular  dullness  every  day.  If  the  pneumonia 
continues  to  increase,  it  may  be  necessary  to  repeat 
the  leeches  in  two  or  three  days  ;  in  a  few  cases  of 
exceptional  severity  (and  pneumonia  in  children 
under  2  years  of  age  is  not  infrequently  fatal)  it  may 
be  advisable  to  use  them  even  a  third  time.     And  in 


262  THE  HEART  OF  THE  CHILD 

considering  the  question  of  bleeding  in  pneumonia, 
remember  that  pallor  of  face  and  smallness  of  pulse 
are  not  necessarily  contra-indications,  for  after  the 
right  side  has  been  relieved  the  pulse  will  be  stronger 
and  the  colour  of  the  cheeks  improved.  You  will 
observe  this  if  you  watch  carefully  the  effect  of  the 
application  of  leeches  in  such  a  condition. 

What  has  been  said  about  the  importance  of 
carefully  ascertaining  the  amount  of  distension  of  the 
right  auricle  in  pneumonia  applies  also  to  certain 
other  pulmonary  affections.  In  acute  bronchitis,  in 
chronic  bronchitis  with  an  acute  exacerbation,  in 
whooping-cough  with  its  mixture  of  collapse,  broncho- 
pneumonia, and  emphysema,  and  in  an  asthmatic 
attack,  it  is  important  to  notice  the  amount  of  disten- 
sion of  the  right  auricle.  It  is  true  that  the  determina- 
tion may  be  difficult  if  the  anterior  base  of  the  right 
lung  is  emphysematous  or  consolidated,  and  it  may 
sometimes  be  impossible  when  there  is  fluid  in  the 
right  pleural  cavity,  but  in  the  great  majority  of  cases 
of  pulmonary  disease  it  can  be  accomplished.  In  all 
cases  of  disease  of  the  left  heart,  especially  when 
it  has  been  injured  by  rheumatism,  it  is  extremely 
important  to  note  carefully  the  amount  of  distension 
of  the  right  auricle.  It  is  not  usually  possible  to 
detect  in  a  primary  rheumatic  attack  an  acute 
dilatation  of  the  right  heart,  such  as  seems  to  occur 
invariably  in  the  left  ventricle.  Nor  is  it  dilated  in  a 
first  attack  of  chorea,  while  the  left  ventricle  almost 


IN  PNEUMONIA  AND  IN  RHEUMATISM     263 

always  is.  Even  when  the  rheumatic  process  has 
damaged  the  left  ventricle  sufficiently  to  interfere 
with  its  suction-action,  and  thus  to  raise  the  tension 
in  the  pulmonary  artery,  the  only  physical  sign  which 
reveals  this  is  the  accentuation  of  the  pulmonary 
second  sound.  For  a  considerable  time  the  right 
ventricle  will  succeed  in  overcoming  the  increased 
tension  without  affording  any  clinical  evidence  of 
hypertrophy  or  dilatation  ;  but  if  the  primary  rheu- 
matic attack  has  been  very  severe,  or  if  a  relapse 
occurs  (and  to  this  rheumatic  children  are  exceed- 
ingly liable,  especially  when  they  are  deprived  of 
salicylates)  and  there  is  evidence  of  pericarditis  or  of 
great  dilatation  of  the  left  ventricle,  then  expect  to 
find  a  gradual  increase  in  the  size  of  the  right  auricle. 
Watch  it  carefully.  If  the  dilatation  of  this  structure 
is  rapid,  dyspnoea  and  cardiac  distress  will  probably 
be  present,  but  a  more  gradual  increase  will  only  be 
revealed  by  percussion.  As  time  passes,  the  heart 
accommodates  itself  as  well  as  it  can  to  its  difficulties; 
and  if  the  rheumatism  does  not  recur,  a  condition  of 
comparative  comfort  may  be  attained  in  which  the 
right  auricle  is  distinctly  dilated  but  not  yet 
grievously  hampered  by  distension.  The  dullness 
in  the  fourth  right  space  may  amount  to  one  and  a 
half  or  two  fingerbreadths,  and  yet  there  is  no  call 
for  relief  by  leeches.  It  is,  however,  a  condition  of 
unstable  equilibrium.  A  fresh  rheumatic  attack  or  a 
little  over-exertion  may  turn   the   scale.     Increased 


264  THE  HEART  OF  THE  CHILD 

dyspncea  reveals  the  greater  strain  ;  the  auricle  dilates 
further,  and  its  dullness  may  amount  to  two  and  a 
half  or  even  three  fingerbreadths  in  the  fourth  right 
space,  one  and  a  half  in  the  third,  and  half  a  finger- 
breadth  in  the  second.  Before  this  the  liver  has 
become  considerably  enlarged.  If  you  find  it  down 
to  the  umbilicus,  or  even  lower,  and  the  amount  of 
urine  passed  be  decreasing,  there  is  no  time  to  be  lost. 
The  condition  is  a  dangerous  one,  but  relief  may  be 
given  by  prompt  venesection  or  leeching.  The 
auricular  dullness  will  then  be  found  to  diminish ; 
the  liver  also  will  be  smaller,  and  the  digitalis,  which 
was  producing  little  or  no  effect  before,  will  manifest 
its  action.  Hypodermic  strychnine  will  assist  in 
restoring  compensation.  It  is  surprising  to  see  how 
much  relief  may  be  given  in  the  later  stages  of  rheu- 
matic heart-disease  by  treatment  of  this  kind,  and  how 
long  life  may  be  preserved  even  when  the  condition 
of  the  heart  is  such  that  the  child  is  incapable  of 
exertion.  But  the  fatal  susceptibility  to  renewed 
attacks  of  rheumatism,  incapacitating  the  heart  still 
more,  at  last  defeats  the  physician. 

Before  leaving  the  right  side  of  the  heart,  I  must 
call  your  attention  to  a  systolic  murmur  over  the 
tricuspid  region  which  is  not  very  uncommon  in 
healthy  children.  It  is  a  low,  soft,  short  murmur,  best 
heard  about  half-way  between  the  left  edge  of  the 
sternum  and  the  nipple-line,  and  usually  becoming 
inaudible  at  a  short  distance  to  the  left  of  this  line. 


LEFT  HEART  IN  NORMAL  CHILD  265 

It  is  sometimes  accompanied  by  slight  irregularity  of 
the  heart's  action.  Its  site  of  maximum  audibility 
is  lower  than  that  of  the  congenital  murmur  already 
described,  and  to  the  right  of  that  of  a  mitral  murmur. 
It  does  not  indicate  any  organic  disease. 

Let  us  now  study  the  left  side  of  the  heart.  The 
left  auricle  is  inaccessible,  but  enlargement  of  the  left 
ventricle  (in  which  enlargement  the  right  ventricle 
probably  shares  to  some  extent)  can  be  easily  deter- 
mined by  careful  percussion,  and  the  strength  of  the 
ventricular  muscle  can  be  fairly  estimated  by  observ- 
ing the  force  and  localisation  of  the  impulse. 

Dilatation  of  the  left  ventricle  being  very  common 
in  children  who  are  out  of  health,  it  is  important  to 
start  with  a  clear  idea  of  the  position  of  the  left  border 
of  the  cardiac  dullness  in  a  normal  child.  Dr  F.  J. 
Foynton  determined  this  carefully  in  35  healthy 
public-school  boys  between  the  ages  of  12  and  14 
years.  In  21  out  of  the  35  boys  the  left  limit  was 
about  one  inch  internal  to  the  nipple,  in  seven  it 
reached  a  vertical  line  through  the  inner  margin  of 
the  areola,  in  five  it  extended  as  far  as  the  vertical 
nipple-line,  and  in  two  it  passed  this  line  by  three- 
quarters  of  an  inch  and  by  one  inch  respectively. 
One  of  these  two  boys,  however,  was  living  in  the 
medical  attendant's  house  because  he  was  delicate,  the 
other  had  recently  suffered  from  influenza.  Thus  we 
may  conclude  that  in  healthy  boys  of  from  12  to  14 
years  of  age  the  left  border  of  the  cardiac  dullness  is 


266  THE  HEART  OF  THE  CHILD 

found  at  about  one  fingerbreadth  internal  to  the 
nipple-line.  In  a  few  it  appears  to  reach  this  line,  and 
this  seems  the  more  common  in  the  younger  children, 
especially  before  7  years  of  age.  In  45  cases  of 
children  under  12  years  old  in  the  surgical  wards  of 
the  Hospital  for  Sick  Children,  Dr  Poynton  found  the 
left  limit  internal  to  the  nipple  in  19,  in  the  nipple- 
line  in  18,  and  external  to  the  nipple  in  8.  But 
of  course  these  were  not  perfectly  healthy  children, 
for  they  were  all  inmates  of  surgical  wards.  We  may 
conclude  that  in  normal  children  the  left  border  of 
the  cardiac  dullness  is  usually  distinctly  internal  to 
the  nipple-line,  that  it  may  sometimes  reach  it,  but 
that  it  rarely  goes  beyond  it.  This  must  be  care- 
fully remembered  when  we  investigate  the  cardiac 
dullness  in  a  child  who  is  suffering  from  disease, 
for  it  is  so  common  to  find  the  left  limit  from 
a  half  to  one  fingerbreadth  external  to  the  nipple-line 
that  we  may  be  led  to  consider  it  as  normal,  and  its 
discovery  to  be  of  no  importance.  But  this  inference 
would  be  false  in  fact  as  well  as  in  logic ;  its  common- 
ness only  proves  that  its  causes  are  many.  The 
cardiac  muscle  of  the  child  is  perhaps  specially  sus- 
ceptible to  the  deleterious  influence  of  toxins  and 
poisonous  products  circulating  in  the  blood. 

The  most  characteristic  instance  of  this  is  diph- 
theria, which  is  much  more  fatal  in  children  than  in 
adults,  sudden  death  being  by  no  means  very  rare 
after  a  severe  attack  of  diphtheria  in  a  child.     The 


DILATATION  OF  LEFT  HEART  367 

fatal  issue  is  usually  caused  by  extensive  fatty 
degeneration  and  destruction  of  the  cardiac  muscular 
fibres,  such  as  Dr  Sidney  Martin  found  to  be  caused 
in  animals  by  injection  of  the  diphtherial  albumoses. 
In  and  after  an  attack  of  diphtheria  in  a  child  there 
is  usually  enlargement  of  the  left  ventricle,  the 
impulse  becomes  diffused  and  weak,  and  the  first 
sound  is  short  and  feeble.  K  the  dil-atation  amounts 
to  two  fingerbreadths  to  the  left  of  the  nipple-line,  the 
danger  of  death  is  great,  and  the  case  should  be  very 
closely  watched.  And  if  the  limit  of  the  dullness  of 
the  left  ventricle  is  only  one  fingerbreadth  outside  the 
nipple-line,  it  must  be  remembered  that  a  rapid 
increase  in  the"  dilatation  may  occur,  even  six  or 
eight  weeks  after  the  diphtherial  attack,  and  may 
cause  sudden  and  entirely  unexpected  death  at  a  time 
when  the  practitioner  is  looking  for  convalescence  and 
has  given  a  hopeful  prognosis.  Influenza,  also,  may 
produce  a  rapid  dilatation  of  the  left  ventricle  which 
may  be  dangerous  to  life,  but  in  this  disease  the  sus- 
ceptibility of  the  child  seems  to  be  less  than  that  of 
the  adult 

The  pneumococcal  toxin  appears  to  affect  the  left 
ventricle  less  than  that  of  influenza,  and  though  there 
is  usually  some  enlargement  of  the  cardiac  dullness  to 
the  left  in  pneumonia,  it  is  much  less  than  the 
enlargement  of  the  right  auricle,  and  one  is  often 
doubtful  whether  the  enlargement  to  the  left  may  not 
be  due  to  dilatation  of  the  right  ventricle  pushing  the 


268  THE  HEART  OF  THE  CHILD 

border  of  the  heart  further  to  the  left.  The  rapid 
recovery  which  often  follows  the  crisis  in  pneumonia 
suggests  that  the  poisonous  influence  of  the  toxin  of 
the  pneumococcus  on  the  left  ventricle  cannot  be  very 
great. 

In  typhoid  fever,  a  gradual  enlargement  of  the  left 
ventricle  is  usually  to  be  detected,  along  with  diffusion 
and  weakening  of  the  impulse :  the  first  sound  also 
becomes  weak  and  short.  The  increase  in  size  often 
reaches  one  fingerbreadth  outside  the  nipple-line,  and 
may  amount  to  two  fingerbreadths.  During  con- 
valescence, the  ventricle  gradually  returns  to  its 
normal  size  and  its  strength  increases.  In  tubercu- 
losis, the  left  ventricle  is  frequently  moderately  dilated. 
How  far  this  is  due  to  a  tuberculous  toxin  and  how 
far  merely  to  general  debility  and  anaemia,  it  is  impos- 
sible to  say.  Even  in  debility  and  in  anaemia  there 
may  be  poisonous  products  of  perverted  metabolism 
circulating  in  the  blood,  and  in  renal  disease  it  is 
quite  likely  that  some  of  the  increase  of  the  dullness 
of  the  left  heart  may  be  due  to  toxaemia  as  well  as  to 
the  influence  on  the  ventricle  of  the  raised  arterial 
tension. 

In  acute  and  subacute  rheumatism  an  enlargement 
of  the  left  ventricle  with  enfeeblement  seems  to  be 
invariable.  It  is  the  first  indication  of  the  efifect  of 
rheumatism  on  the  heart,  and  may  be  detected  when 
there  is  no  evidence  of  endocarditis  or  pericarditis. 
The  left  border  of  the  cardiac  dullness  almost  always 


INCREASE  OF  CARDIAC  DULLNESS       269 

extends  beyond  the  nipple-line,  even  in  the  most 
subacute  attack  ;  usually  it  reaches  one  fingerbreadth 
to  the  left  of  this  line,  and  it  may  be  even  two  finger- 
breadths  to  the  left  in  a  first  attack  of  rheumatism  in 
which  there  is  neither  rub  nor  murmur.  The  impulse 
is  diffused,  and  both  it  and  the  first  sound  are 
weakened.  As  the  attack  subsides,  the  dullness  tends 
to  return  to  the  normal  limit.  It  may  do  so  com- 
pletely, but  in  many  instances,  especially  when  a 
murmur  becomes  audible,  the  left  ventricle  remains 
more  or  less  dilated.  A  second  attack — and  to  this  a 
rheumatic  child  is  extremely  liable — dilates  it  further, 
and  an  accompaniment  of  endocarditis  is  only  too 
probable.  Pericarditis  may  occur  in  a  first  attack,  but 
is  usually  a  later  phenomenon.  When  it  occurs  it  is 
always  accompanied  by  great  enlargement  of  the 
heart,  causing  an  extensive  increase  in  cardiac  dull- 
ness, usually  ascribed  wholly  to  pericardial  effusion. 
After  repeated  rheumatic  attacks  the  child's  heart  may 
reach  a  size  which  is  almost  incredible  to  anyone  who 
has  not  observed  it  in  the  wards  and  post-mortem 
room.  Clinically,  it  may  extend  four  fingerbreadths 
to  the  left  of  the  nipple-line  and  three  fingerbreadths 
in  the  fourth  right  intercostal  space.  In  the  larger 
rheumatic  hearts  there  is  usually  a  systolic  apex- 
murmur,  and  frequently  a  presystolic  or  mid-diastolic 
also.  Evidence  of  pericardial  friction,  more  or  less 
extensive,  is  common.  Occasionally  a  diastolic 
murmur  at  the  base  gives  proof  of  aortic  regurgita- 


270  THE  HEART  OF  THE  CHILD 

tion.  It  has  long  been  known  that  in  children  the 
cardiac  manifestations  of  rheumatism  often  are  far 
more  pronounced  than  any  other  indications  of  the 
disease.  There  may  be  little  or  no  arthritis,  no  sore- 
ness of  throat,  no  eruption  or  only  a  very  small  patch 
of  erythema,  no  subcutaneous  nodules,  no  chorea  or 
only  slight  nervous  twitching,  yet  the  cardiac 
rheumatism  may  be  nothing  less  than  deadly.  If  all 
who  have  to  do  with  children  would  constantly  bear 
this  in  mind,  much  suffering  would  be  avoided  and 
many  lives  would  be  saved.  The  slightest  suspicion 
of  rheumatism  should  lead  to  a  most  careful  examina- 
tion of  the  child's  heart  by  palpation  and  percussion  ; 
the  practitioner  who  in  this  matter  relies  solely  upon 
auscultation  betrays  a  carelessness  which  is  almost 
criminal,  and  shows  himself  unfit  to  be  entrusted  with 
the  vital  interests  of  the  child. 

In  chorea,  an  enlargement  of  the  left  ventricle,  with 
or  without  murmur,  is  present  in  the  great  majority 
of  cases.  The  left  border  of  the  dullness  almost 
always  extends  from  a  half  to  one  fingerbreadth  out- 
side the  nipple-line.  This  seems  to  be  an  additional 
confirmation  of  the  essentially  rheumatic  nature  of 
nearly  all  cases  of  chorea — one  extra  link  in  the  chain 
of  proof 

The  extreme  tendency  to  cardiac  disease  in  rheu- 
matism and  in  chorea  seems  to  be  not  merely  the 
result  of  the  poisonous  influence  of  a  toxaemia.  This, 
no  doubt,  is  a  part  of  the  deleterious  action  produced 


RHEUMATISM  AND  CHOREA  271 

by  rheumatism,  and  it  may  perhaps  sometimes  be 
the  sole  cause  in  a  slight  attack  which  recovers  com- 
pletely, but  evidence  is  accumulating  to  prove  that 
there  is  usually  very  much  more  than  this — that 
actual  inflammation  of  the  muscular  substance  and 
fibrous  structures  of  the  heart  exists,  and  that  this  is 
caused  by  the  local  presence  of  a  diplococcal  micro- 
organism. Dr  Poynton  and  Dr  A.  Paine  have  demon- 
strated such  organisms  in  the  cardiac  valves  (with 
intact  epithelium)  and  in  the  muscular  wall.  The 
same  investigators  have  proved  that  pericardial  fluid 
from  a  rheumatic  child  when  injected  intravenously 
into  rabbits  can  cause  in  these  animals  all  the  most 
characteristic  effects  of  rheumatism  in  the  child. 
They  have  also  obtained  from  a  rheumatic  nodule  in 
a  child,  carefully  excised  with  aseptic  precautions,  a 
most  abundant  growth  of  the  typical  diplococci  in 
pure  culture.  In  rheumatism,  then,  we  are  dealing 
with  an  inflammation  of  the  child's  most  important 
organ  caused  by  the  local  presence  of  a  pernicious 
micro-organism. 

The  question  of  treatment  at  once  divides  itself 
into  two  problems :  Can  we  by  the  administration 
of  drugs  directly  destroy  these  microbes,  or  arrest 
their  growth  and  increase,  without  damage  to  the 
child?  and  have  we  any  means  of  directly  repressing 
the  cardiac  inflammation  ? 

To  the  first  question  I  reply  that  in  sodium  salicy- 
late, in  adequate  doses,  we  have  a  drug  which  seems 


272  THE  HEART  OF  THE  CHILD 

to  be  definitely  antagonistic  to  the  rheumatic  process. 
The  theory  that  it  merely  relieves  pain  is  only  pos- 
sible when  adults  are  the  subjects  of  the  disease ;  in 
the  child  it  is  at  once  seen  to  be  absurd.  The  best 
proof  of  the  genuine  efficacy  of  salicylate  in  arresting 
rheumatism  is  found  in  the  great  tendency  to  relapse 
when  the  drug  is  being  administered  in  doses  which 
are  too  small,  and  especially  when  it  is  too  soon  given 
up.  There  is  a  widespread  impression  that  salicylate 
of  soda  is  "  depressing  to  the  heart."  What  is  really 
depressing  to  the  heart  is  the  rheumatic  microbe,  its 
works  and  ways,  and  some  of  its  pernicious  effects 
have  been  attributed  to  the  salicylate.  Children  bear 
salicylate  well,  and  it  rarely  causes  in  them  the 
unpleasant  aural  symptoms  which  are  common  in  the 
adult.  It  seems  to  be  almost  as  necessary  to  a  rheu- 
matic child  as  mercury  is  to  a  syphilitic  infant,  and 
some  children  with  great  tendency  to  rheumatic 
relapse  ought  to  take  a  small  quantity  of  the  drug 
daily  for  a  long  time.  Sodium  bicarbonate  is  another 
drug  which  seems  to  be  certainly  useful  in  rheu- 
matism. It  may  be  given  in  double  the  dose  of  the 
salicylate  and  along  with  it.  My  impression  is  that  the 
acute  dilatation  of  the  left  ventricle  subsides  more 
rapidly  when  the  bicarbonate  has  been  freely  given 
than  when  the  salicylate  has  been  administered  alone. 
The  question  whether  we  have  any  means  of 
repressing  the  cardiac  inflammation  may  also  be 
answered  with  confidence.     Leeches  will  diminish  the 


MEANS  OF  TREATMENT  273 

congestion  of  the  cardiac  vessels,  even  when  applied 
over  the  liver,  by  lessening  the  pressure  in  the  right 
auricle  and  thus  aiding  the  escape  of  the  blood  in  the 
coronary  sinus  and  the  intra-cardiac  venules,  and  the 
local  application  of  an  icebag  most  certainly  represses 
the  cardiac  inflammation.  These  two  remedies  are 
of  the  greatest  possible  service  to  the  rheumatic  heart. 
Ice  would  be  depressing  'to  the  normal  heart,  but 
when  preceded  by  leeches  and  used  with  care  it  is  the 
reverse  of  depressing  to  the  rheumatic  heart.  It 
relieves  the  depression  caused  by  the  rheumatism, 
and  under  its  use  I  have  often  watched  the  dilated 
ventricle  diminish  and  the  feeble  diffused  impulse 
become  changed  into  a  steady,  heaving,  local  thrust. 
Digitalis  is  of  little  service  in  the  treatment  of  rheu- 
matic cardiac  inflammation  in  the  child  ;  its  oppor- 
tunity is  later,  when  the  inflammation  has  subsided 
and  the  mechanical  effects  of  the  cardiac  lesions 
manifest  themselves.     Then  it  will  work  wonders. 

When  we  pass  from  inflammatory  conditions  of 
the  heart  to  the  ventricular  dilatation  and  enfeeble- 
ment  caused  by  toxaemia,  we  see  that  leeches  and  ice 
are  inapplicable.  Digitalis  is  sometimes  of  service, 
but  the  hypodermic  injection  of  strychnine  is  of  still 
greater  utility.  Iron  is  of  value  in  anaemic  debility, 
but  in  diphtheria  I  rely  mainly  upon  subcutaneous 
injection  of  atropine  when  danger  threatens.  I  first 
employed  belladonna  in  diphtherial  paralysis  more 
than  twenty  years  ago  on  physiological  grounds.     It 

S 


274  THE  HEAHT  OF  THE  CHILD 

has  subsequently  been  continually  employed  at  the 
Hospital  for  Sick  Children,  and  I  believe  I  have  seen 
it  save  many  lives.  In  cases  of  less  urgency  the 
drug  may  be  given  by  the  mouth,  but  where  the 
dullness  of  the  left  ventricle  extends  more  than  one 
fingerbreadth  to  the  left  of  the  nipple-line  it  should  be 
given  subcutaneously,  with  a  frecjuency  regulated  by 
the  imminence  of  the  danger. 


THE  PATHOLOGY  AND  TREATMENT  OF 
CHOREA. 

{The  Introduction  to  a  Discussion  in  the  Sectioii  of  Diseases  of 
Children  at  the  Swansea  Meeting  of  the  British  Medical 
Association^  July  1903.) 

Our  subject  tg-day  is  the  pathology  and  treatment 
of  that  common  disease  of  childhood  which  is  so 
inadequately  and  incorrectly  described  by  the  name 
"chorea."  Inadequately,  for  there  is  much  more 
than  abnormal  muscular  movement  in  this  malady. 
Incorrectly,  for  whatever  else  a  choreic  patient  may 
do,  there  is  a  total  absence  of  any  rhythmic  move- 
ment which  might  fairly  be  described  as  "  dancing." 
It  is  most  unfortunate  that  the  name  should  wholly 
misrepresent  the  disease.  Perhaps,  when  the  path- 
ology is  completely  understood,  a  better  name  may 
be  invented.  Meantime  let  us  define  our  subject  by 
excluding  all  varieties  of  hysteria,  all  forms  of  habit- 
spasm,  and  all  irregularities  of  movement  resulting 
from  gross  cerebral  lesions,  such  as  athetosis  and 
"  post-hemiplegic  chorea."  And  in  this  Section  we 
neglect  the  rarer  chorea  of  adults  and  of  old  age,  and 

275 


276  PATHOLOGY  AND  TREATMENT  OF  CHOREA 

concern  ourselves  only  with  the  so-called  "  chorea  "  of 
childhood. 

The  most  obvious  fact  in  chorea  is  disorderly 
muscular  movement,  spasmodic,  clonic,  irregular,  in- 
voluntary, with  imperfect  control  and  co-ordination. 
If  we  observe  carefully  the  distribution  of  these  in- 
voluntary movements,  we  find  that  it  is  precisely  the 
muscles  over  which  we  have  most  voluntary  power 
that  are  most  affected  in  chorea — the  muscles  of  the 
face,  those  of  the  tongue,  and  those  of  the  hands  and 
arms.  These  are  the  muscles  which  specially  express 
emotion — by  grimace,  speech,  and  the  movements  of 
the  hands  and  arms  which  naturally  accompany 
eloquent  or  excited  speech,  especially  in  the  more 
emotional  races.  It  is  precisely  these  muscles  which 
are  most  affected  in  chorea;  the  face,  tongue,  and 
hands  are  much  more  implicated  than  the  proximal 
parts  of  the  upper  limbs,  the  upper  limbs  more  than 
the  lower,  and  the  lower  limbs  more  than  the  muscles 
of  the  trunk. 

Respiration,  over  which  we  have  a  real  though 
limited  control,  is  affected  much  more  than  the  action 
of  the  heart,  over  which  we  have  no  voluntary  power 
whatever.  The  heart's  action  may,  indeed,  be  irregular 
in  chorea,  but  it  is  much  less  so  than  the  respiration, 
and  the  heart  often  works  steadily  enough  while  the 
breathing  is  quite  irregular.  Choreic  movements  are 
often  more  pronounced  on  one  side  of  the  body  than 
on  the  other,  and  in  slight  cases  they  may  be  limited 


IRRITABILITY  OF  MOTOR  CORTEX        277 

to  the  limbs  of  one  side.  Choreic  movements  cease 
when  the  patient  falls  asleep,  and  recur  when  he 
wakes. 

These  facts,  taken  together,  indicate  unmistakably 
a  disorder  of  the  brain,  and  specially  of  the  motor 
centres.  In  the  Rolandic  area  of  the  cortex  much 
space  is  allotted  to  the  movements  which  are  specially 
under  voluntary  direction*  and  control — to  the  face, 
hand,  and  arm — less  to  the  lower  limbs  in  proportion 
to  their  size,  and  comparatively  little  to  the  muscles 
of  the  back  and  of  the  abdomen.  The  relative 
affection  of  the  different  muscular  movements  in 
chorea  corresponds  to  the  cortex  arrangement. 

It  is  clear  tHat  in  chorea  these  centres  are  in  an 
abnormally  excited  state,  for  if  you  ask  a  choreic 
child  a  question,  its  hands  will  often  reply  before  its 
mouth.  Place  the  child  at  rest,  with  its  arms  and 
hands  outstretched  on  the  bed,  and  wait  for  a  quiet 
interval  when  the  choreic  movements  have  ceased,  or 
are  at  all  events  much  diminished.  Then  ask  the 
child  a  question,  however  simple,  its  name,  or  the 
number  and  names  of  its  brothers  and  sisters.  Usually 
the  choreic  movements  recur  at  once  in  the  hands, 
often  before  the  reply  is  uttered  ;  or  if  they  have  not 
previously  ceased,  they  become  very  rapidly  much 
more  violent.  It  seems  that  the  outgoing  impulse  to 
the  speech-centre  finds  the  adjoining  centres  of  the 
motor  area  abnormally  excitable,  and  overflows  into 
them.     Sometimes  the  choreic  movements  follow  so 


278  PATHOLOGY  AND  TREATMENT  OF  CHOREA 

quickly  after  the  question  that  it  almost  seems  as  if  the 
ingoing  auditory  impulse  had  reached  them  directly. 

Similarly,  if  the  child  squeezes  an  object  firmly 
with  one  hand  the  other  hand  usually  becomes  more 
decidedly  choreic.  In  a  case  of  hemichorea,  a  strong 
squeeze  with  the  unaffected  hand  brings  out  additional 
movements  in  the  choreic  hand,  while  a  squeeze  with 
the  affected  hand  produces  little  or  no  effect  on  the 
other.  This  seems  to  indicate  clearly  that  the  hand- 
centre  in  the  cortex  on  the  one  side  is  more  excitable 
than  that  on  the  other. 

The  motor  centres  are  not  only  irritable,  they  are 
also  weak.  This  weakness  may  be  obvious  from  the 
first,  but  it  is  apt  to  become  greater  as  the  irritability 
subsides.  The  grasp  is  feeble,  and  the  weakness  of 
the  whole  upper  limb  may  be  so  great  as  to  deserve 
the  name  of  paresis.  When  the  hands  and  arms  are 
outstretched,  the  child  standing  or  sitting,  there  is 
usually  a  slight  flexion  of  the  wrist,  apparently  due 
to  loss  of  tone  of  the  special  extensors,*  and  the 
voluntary  extensor  effort  of  the  common  extensor  of 
the  fingers  slightly  over-extends  the  first  phalanges. 
It  may  be  impossible  for  the  patient  to  walk,  to  stand, 
to  rise  from  the  recumbent  position,  almost  impossible 
even  for  him  to  lift  one  leg  over  the  other. 

*  Dr  Beevor  showed,  in  the  Croonian  Lectures  of  this  year, 
that  no  obvious  contraction  of  the  extensors  of  the  wrist  can 
be  detected  until  the  extensor  of  the  fingers  has  to  overcome 
a  resistance  of  at  least  3  lb.,  but  the  choreic  hand  seems  to 
indicate  a  loss  of  at  least  a  normal  tonus. 


APHASIA  AND  EMOTIONAL  STORMS       279 

In  a  severe  case  the  weakness  of  the  tongue  and 
lips  is  great,  so  that  feeding  is  difficult,  and  speech 
becomes  too  great  an  effort.  The  laryngeal  muscles 
may  share  in  this  weakness.  But  often  there  seems 
to  be  something  more  than  mere  weakness  of  the 
muscular  mechanisms  involved  in  speech,  for,  though 
these  muscles  are  never  completely  paralysed  in 
chorea,  speech  may  be'  altogether-  lost  for  weeks  or 
even  for  months.  I  have  seen  several  cases  in  which 
speech  was  impossible  for  six  or  eight  weeks,  and  one 
case  in  which  it  was  absent  for  eight  months.  This 
child  made  at  last  a  complete  recovery,  and  she  was 
subsequently  in  the  same  ward  for  another  but  slighter 
attack  of  chorea,  in  which  her  speech  was  not  impaired. 
In  such  cases  it  is  impossible  to  resist  the  belief  that 
the  motor  speech-centre  is  itself  affected.  Thus  we 
have  an  indication  that  the  muscular  movements  and 
weakness  are  not  the  only  evidence  of  a  disorder  of 
the  brain  in  chorea.  This  inference  is  often  confirmed 
by  the  very  first  attempt  at  conversation  with  a 
choreic  child,  for  even  the  most  kindly  question  will 
sometimes  provoke  an  emotional  storm.  The  child 
begins  to  cry  without  any  obvious  cause ;  this  may 
pass  away  quickly,  or  the  crying  may  become  violent. 
When  it  has  ceased,  he  cannot  tell  you  why  he  cried, 
and  he  will  sometimes  acknowledge  that  there  was 
nothing  to  cry  for.  Such  attacks  may  be  accompanied 
by  great  excitement,  and  even  by  hallucinations  of 
vision  ;  they  then  fairly  deserve  to  be  called  maniacal. 


280  PATHOLOGY  AND  TREATMENT  OF  CHOREA 

In  the  absence  of  emotional  attacks  there  is  often  a 
listless,  vacant  look  on  the  face  of  a  choreic  child 
which  in  health  was  alert  and  intelligent.  This  may 
be  due  in  part  to  weakness  and  loss  of  tone  of  the 
facial  muscles  of  expression,  but  it  is  probably  also 
the  result  of  a  mental  dullness  caused  by  the  disease ; 
for  mental  dullness  and  loss  of  memory  are  often 
obvious  enough.  The  answers  to  the  very  simplest 
questions  in  mental  arithmetic  are  often  absurdly 
wrong ;  and  when  the  child  is  asked  to  repeat  the 
alphabet,  one  or  two  letters  are  frequently  omitted. 
Alterations,  also,  in  temper  and  disposition  are  often 
complained  of  by  the  mothers. 

Whether  there  is  impairment  of  the  sensory  activities 
of  the  brain,  general  or  special,  it  is  difficult  to  say. 
Choreic  children  are  not  often  definitely  hyperaesthetic, 
and  marked  anaesthesia  is  not  a  symptom  of  chorea, 
though  it  may  occur  in  older  children  who  are  also 
hysterical.  Possibly  there  is  sometimes  a  general 
lowering  of  sensibility. 

Thus  it  is  clear  that  in  chorea  much  more  than  the 
Rolandic  area  of  the  cortex  is  affected,  and  it  is 
probable  that  the  whole  brain  suffers  more  or  less. 
Is  the  cord  affected  also  ?  If  so,  its  affection  is  over- 
shadowed by  that  of  the  brain,  as  in  tuberculous 
meningitis.  But  one  phenomenon  is  observed  which 
may  indicate  an  extra  irritability  of  the  spinal  ganglion 
cells — an  increase  in  the  briskness  of  the  knee-jerks 
and  a  tendency  to  a  prolonged  extension  of  the  knee 


PROBABLY  TOXEMIC  281 

when  the  patellar  tendon  is  struck.  Possibly  also  the 
atonic  condition  of  the  wrist-extensors  may  be  of 
spinal  origin. 

Are  the  peripheral  nerves  affected  ?  Choreic 
children  sometimes  complain  of  flying  pains  in  the 
limbs,  away  from  the  joints,  which  may  possibly  be 
neuritic.  In  some  cases  of  chorea  the  knee-jerks 
cannot  be  obtained,  though  it  is  not  certain  that  this 
is  really  a  symptom  of  the  disease,  or  how,  if  a 
symptom,  it  is  produced.  And  the  occasional  occur- 
rence of  slight  optic  neuritis,  mentioned  by  Sir  William 
Gowers,  must  also  be  remembered.  It  may  be  added 
that  choreic  children  often  suffer  from  constipation ; 
the  cause  of  thfs  is  uncertain. 

In  chorea,  then,  there  seems  to  be  a  disorder  of  the 
whole  cerebral  cortex,  probably  of  the  whole  brain, 
possibly  of  the  nervous  system  in  general,  sufficient 
to  produce  very  definite  symptoms,  and  often  lasting 
for  a  long  time.  Yet  the  disorder  is  not  a  destructive 
one ;  it  usually  ends  in  complete  recovery.  The 
pathological  changes  are,  therefore,  if  organic,  of 
slight  intensity,  and  it  seems  probable  that  the  morbid 
state  may  be  largely  due  to  a  toxaemia.  Yet  the 
fact  that  the  symptoms  may  be  very  definitely 
localised  suggests  that  the  cause  cannot  be  simply  a 
toxaemia ;  there  must  be  something  focal  as  well. 
The  changes  found  post-mortem  in  the  brains  of  the 
few  cases  which  end  fatally  have  been  mainly  confined 
to   the   vascular   system  —  hyperaemia,   dilatation   of 


282  PATHOLOGY  AND  TREATMENT  OF  CHOREA 

vessels,  perivascular  leucocytes,  thromboses,  and  slight 
haemorrhages.  Alterations  in  the  nerve-cells  have 
also  been  found  by  several  observers.  A  recent 
investigation  of  two  fatal  cases  by  modern  histological 
methods  by  Dr  Reichardt  of  Chemnitz  *  showed 
small  haemorrhages,  irregularly  scattered,  with 
collections  of  leucocytes,  chiefly  mononuclear,  and 
dilatation  of  vessels,  with  perivascular  small-celled 
infiltration,  in  many  parts  of  the  brain,  in  varying 
amount.  No  changes  were  detected  in  the  ganglion 
cells,  but  there  were  areas  of  fatty  degeneration  of 
nerve-fibres  ;  in  the  spinal  cord  the  parts  most  affected 
were  the  root-fibres,  and  the  anterior  and  lateral 
horns,  and  the  posterior  columns — the  anterior  and 
lateral  tracts  were  free.  Cultures  from  the  fluid  of 
the  cerebral  ventricles  of  the  first  case  gave  no  result, 
but  "  staphylococcus  aureus  "  was  obtained  from  the 
heart-blood.  In  the  second  case  there  were  "strepto- 
cocci "  in  the  cardiac  valves,  and  a  few  colonies  of 
"  staphylococcus  albus  "  were  obtained  from  the  brain. 
If  we  look  for  clinical  evidence  of  a  morbid  blood- 
state  in  chorea,  we  find  that  it  is  frequently  accom- 
panied by  manifestations  of  the  toxaemia  which  we 
call  "  rheumatism."  Any  of  the  ordinary  rheumatic 
phenomena  in  a  child  may  accompany  chorea — 
tonsillitis,  arthritis,  erythema,  nodules,  cardiac  dilata- 
tion, endocarditis,  pericarditis,  pleurisy.     The    most 

*  Deiitsches  Archiv  fiir  klinische  Medicin^  1902,  p.  504.     For 
this  reference  I  am  indebted  to  my  colleague,  Dr  Batten. 


CHOREA  AND  RHEUMATISM  283 

frequent  of  these  is  cardiac  dilatation  ;  for  in  chorea, 
as  in  rheumatism,  the  left  ventricle  is  almost  always 
too  large,  the  left  border  of  the  heart  extending 
beyond  the  left  nipple-line,  often  as  much  as  one 
fingerbreadth,  and  the  first  sound  being  feeble.  The 
next  commonest  is  a  systolic  apex-murmur  :  whether 
this  is  always  due  to  valvulitis  is  uncertain,  but  in 
many  cases  it  is  so  undoubtedly.  4n  almost  all  fatal 
cases  of  chorea  recent  vegetations  are  found  on  the 
mitral  valve.  A  fairly  frequent  evidence  of  rheumatism 
is  the  rheumatic  nodule,  single  or  multiple.  The 
neighbourhood  of  the  various  joints,  also  the  tendons 
of  the  hands  and  feet,  the  occiput,  and  the  vertebral 
spinous  processes  ought  to  be  carefully  examined  for 
nodules  in  all  cases  of  chorea.  The  other  manifesta- 
tions of  rheumatism  must  also  be  borne  in  mind,  and 
special  care  should  be  taken  not  to  overlook  a  peri- 
cardial rub. 

With  regard  to  the  relations  of  rheumatism  and 
chorea,  I  may  repeat  what  I  wrote  in  my  article  on 
rheumatism  in  Allchin's  Manual  of  Medicine :  "  The 
relationship  between  the  two  affections  needs  further 
elucidation,  but  the  more  carefully  they  are  studied 
the  more  intimate  it  is  found  to  be.  Choreic 
symptoms  of  slight  intensity  are  common  in  children 
suffering  from  acute  or  subacute  rheumatism  ;  and 
when  there  is  no  definite  chorea  there  may  sometimes 
be  seen  the  tendency  to  emotional  disturbance — the 
causeless  and  transient  fits  of  crying  which  are  so 


284  PATHOLOGY  AND  TREATMENT  OF  CHOREA 

often  observed  in  chorea.  The  onset  of  a  severe 
chorea  frequently  follows  two  or  three  weeks  after  the 
occurrence  of  symptoms  which,  though  slight,  were 
definitely  rheumatic.  During  an  attack  of  chorea 
undoubted  symptoms  of  rheumatism  may  manifest 
themselves.  Many  cases  of  chorea  which  have  appar- 
ently at  the  time  no  connection  with  rheumatism 
suffer  from  an  attack  of  that  disease  a  year  or  two 
later.  After  making  allowance  for  possible  coinci- 
dences, the  conclusion  is  irresistible  that  there  is  some 
very  close  connection  between  the  two  diseases,  and 
that  in  many  cases  chorea  must  be  looked  upon  as  a 
definitely  rheumatic  symptom." 

I  draw  special  attention  to  the  fact  that  chorea  is 
often  the  first  of  a  series  of  rheumatic  attacks.  If 
this  be  ignored,  and  the  relationship  of  the  two 
diseases  be  based  simply  on  the  precedence  of  rheu- 
matism, the  connection  of  the  two  will  inevitably  be 
understated.  It  occurred  to  me  that  it  would  be 
worth  while  to  investigate  carefully  the  amount  of 
subsequent  rheumatism  occurring  within  a  few  years 
after  an  attack  of  chorea  in  children  who  had  had  no 
rheumatism  previously.  Dr  Batten  was  good  enough 
to  investigate  this  point  in  the  out-patient  department 
of  the  Hospital  for  Sick  Children.* 

He  found  in  115  cases  of  chorea  that  whereas  the 
percentage  of  previous  rheumatism  was  stated  to  be 
only  32.2  per  cent,  three  years  later  so  many  of  them 
■*  Lancet^  1895,  ii-  P-  ii95- 


CHOREA  FOLLOWED  BY  RHEUMATISM    285 

had  subsequently  suffered  from  rheumatism  that  the 
percentage  rose  to  43.5,  and  three  years  later  still  it 
had  risen  to  53.2,  so  that  the  lapse  of  six  years  had 
increased  the  percentage  by  21  per  cent.  And  this 
is  below  the  truth,  for  after  the  lapse  of  six  years  as 
many  as  38  of  the  115  children  could  not  be 
investigated.  If  the  same  proportion  of  these  missing 
ones  had  become  rheumatic,  the  percentage  would  be 
increased,  not  by  21,  but  by  28  per  cent.  This  added 
to  the  cases  of  "  previous  "  rheumatism  would  give  a 
total  percentage  of  60  per  cent. 

And  even  these  figures  are  probably  too  low. 
When  we  remember  that  pain  and  swelling  of  joints, 
which  alone  constitute  the  ordinary  idea  of  "  rheu- 
matism," are  slight  and  infrequent  in  the  rheumatism 
of  childhood,  and  that  its  sole  and  yet  conclusive 
manifestation  may  be  a  subcutaneous  nodule,  or  a 
small  patch  of  erythema,  or  a  dilated  heart  with  a  soft 
mitral  murmur,  one  sees  that  statistics  which  are  to 
represent  fairly  the  relation  between  the  two  diseases 
must  be  made  with  the  greatest  care.  All  the  points 
mentioned  by  Dr  Cheadle  in  his  Harveian  Lectures 
must  be  borne  in  mind.  For  these  reasons,  many 
published  statistics  on  the  connection  of  chorea  with 
rheumatism  greatly  understate  the  facts. 

The  clinical  evidence  is  in  reality  very  strong,  and 
we  turn  with  interest  to  the  excellent  work  of  Drs 
Poynton  and  Paine  on  the  bacteriology  of  rheumatism 
to  learn  whether  they  can  throw  light  on  the  patho- 


286  PATHOLOGY  AND  TREATMENT  OF  CHOREA 

logy  of  chorea.  I  need  not  remind  you  that  these 
observers,  by  a  series  of  investigations,  have  isolated 
from  the  tissues  in  cases  of  fatal  rheumatism,  and  also 
from  the  blood  of  rheumatic  patients  during  life,  a 
diplococcus  which  they  have  been  able  to  cultivate, 
and  which  when  injected  intravenously  into  rabbits 
has  produced  in  them  all  the  symptoms  of  a  violent 
rheumatism  in  a  child,  and  that  a  recent  subcutaneous 
rheumatic  nodule,  excised  with  aseptic  precautions 
two  hours  after  death,  at  once  immersed  in  a  suitable 
medium  and  cultivated  for  forty-eight  hours  in  an 
incubator,  was  found  to  contain  an  exuberant  growth 
of  this  organism  without  the  presence  of  any  other. 
In  my  judgment  these  results  are  decisive. 

Accepting,  then,  the  fact  as  now  demonstrated  that 
rheumatism  is  a  disease  caused  by  a  diplococcus,  and 
remembering  its  close  clinical  connection  with  chorea, 
we  ask  with  interest  whether  this  diplococcus  is  also 
responsible  for  the  production  of  chorea.  The  evi- 
dence on  this  point  is  as  yet  scanty,  but  it  is  extremely 
suggestive.  One  of  the  rabbits  injected  with  a  culture 
of  this  diplococcus  obtained  by  incubating  peri- 
cardial fluid  from  a  fatal  case  of  rheumatism,  developed 
symptoms  remarkably  resembling  chorea  in  a  child — 
clonic,  irregular,  involuntary,  spasmodic,  muscular 
movements,  especially  of  the  forelimbs  and  of  the 
face,  with  a  condition  of  "  nervousness  "  such  that  it 
started  at  any  sudden  noise.  This  rabbit  was  killed, 
and  diplococci  were  found  in  the  lymphatic  sheath  of 


BACTERIOLOGY  287 

the  vessels  in  the  pia  mater  and  in  the  endotheHal 
cells  of  the  blood-capillaries  penetrating  the  cortex  of 
the  brain. 

A  second  fact  is  this.  Dr  Poynton  cut  sections  of 
the  brain  of  a  fatal  case  of  chorea  which  had  been 
preserved  for  three  years,  and  found  diplococci  in  the 
cortex  itself,  also  in  profusion  in  the  mitral  valve. 
These,  however,  were  not  cultivated^  so  that  it  is  not 
proved  that  these  were  the  rheumatic  diplococci. 
Yet  if  we  take  these  two  facts  together,  and  remember 
that  Dana,  Apert,  Wassermann,  and  others  have 
isolated  a  diplococcus  from  the  brain  in  fatal  cases 
of  chorea,  it  becomes  more  than  probable  that 
before  long  the  demonstration  will  be  made  complete. 
Fatal  cases  of  chorea  are  happily  uncommon,  and 
it  will  require  some  time  before  the  point  can  be 
proved. 

But  if  it  has  been  shown  that  these  diplococci  are 
almost  always  found  in  the  heart  in  fatal  cases  of 
rheumatism,  and  if  they  have  actually  been  found  in 
the  blood  during  life,  it  seems  certain  that  they  must 
often  reach  the  cerebral  circulation.  If  their  presence 
in  the  pial  vessels  and  the  cortex  is  the  cause  of 
chorea,  we  must  look  upon  this  disease  as  a  microbic 
invasion  of  the  brain,  as  in  tuberculous  meningitis. 
Why  the  result  is  so  different  in  these  two  diseases 
must  depend  upon  a  difference  in  the  virulence  of  the 
microbe,  and  the  different  measure  of  resistance  on 
the    part    of    the    phagocytes   and    other   defensive 


288  PATHOLOGY  AND  TREATMENT  OF  CHOREA 

mechanisms.  In  this  respect  some  recent  observa- 
tions by  Drs  Poynton  and  Paine  are  of  interest. 
They  found  that  in  the  arthritis  of  rheumatism  the 
fluid  effusion  is  usually  sterile  ;  that  the  diplococci 
are  present  in  the  synovial  membrane  of  the  inflamed 
rheumatic  joint,  but  that  they  are  there  seized  upon 
by  the  phagocytic  cells,  and  that  the  diplococci 
contained  in  these  cells  are  so  much  devitalised  that 
they  can  no  longer  be  cultivated. 

Why  the  rheumatic  diplococci  should  cause  chorea 
in  children  and  not  in  adults ;  why  some  rheumatic 
children  should  become  choreic  and  others  not ;  and 
why  girls  should  be  choreic  three  times  as  frequently 
as  boys,  must  depend  upon  differences  of  individual 
power  of  resistance.  Even  if  the  actual  presence  of 
the  micro-organisms  cannot  be  demonstrated  in  the 
cerebral  blood-vessels  and  membranes  in  fatal  cases 
of  chorea,  it  is  still  possible  that  the  "  irritable  weak- 
ness" of  the  cortical  cells  may  be  due  to  poisoning 
by  their  toxin,  just  as  the  toxin  of  th'^  diphtheria 
bacillus  selects  certain  parts  of  the  central  nervous 
system.  If  the  toxin  alone  is  the  active  agent,  the 
analogy  would  be  with  diphtheria ;  if  the  organisms 
themselves  are  present  in  the  cerebral  membranes,  the 
analogy  would  be  with  tuberculosis.  A  similar  doubt 
exists  with  regard  to  the  dilatation  of  the  left  ventricle 
caused  by  rheumatism  —  is  it  always  due  to  the 
presence  of  the  diplococci  in  the  cardiac  muscle,  or 
may  the  toxin   alone  be  sometimes  ^effective?     The 


OTHER  POSSIBLE  CAUSES  289 

decision    of    this    question    must    be    left    to    future 
research. 

Are  we,  then,  to  say  that  chorea  is  "  cerebral  rheu- 
matism "  ?  Yes,  if  we  add,  "  in  the  great  majority 
of  cases."  But  we  must  not  make  the  statement 
absolutely,  for  other  microbes  and  other  toxins  may 
perhaps  affect  the  cortical  cells  in  the  same  way  as 
the  rheumatic  diplococci'  and  their  ~toxin,  just  as  the 
bacillus  coli  and  the  bacillus  enteritidis  of  Gaertner 
may  produce  a  continued  fever  resembling  that  caused 
by  the  typhoid  bacillus  ;  and,  to  say  nothing  of  "  senile 
chorea,"  the  disease  known  as  Huntingdon's  chorea 
is  found  to  be  caused  by  multiple  organic  sclerotic 
changes  in  the  cortex.  It  is  even  possible  that  the 
sudden  emotional  disturbance  caused  by  fright  may 
in  some  way  disturb  the  nutrition  of  the  cortical  cells 
in  a  susceptible  brain  in  a  way  similar  to  the  altered 
nutrition  caused  by  the  rheumatic  toxin.  Sir  William 
Gowers  reminds  us  that  throughout  the  animal 
kingdom  the  emotion  of  alarm  has  a  direct  effect  on 
the  motor  centres  essential  to  the  safety  of  the  animal 
alarmed.  Cases  of  chorea  really  caused  by  fright,  in 
the  absence  of  rheumatism,  are  rare,  but  they  prob- 
ably exist ;  the  difficulty  is  to  prove  the  absence  of 
rheumatism. 

I  desire  then  to  maintain  that  every  case  of  chorea, 
however  mild,  ought  to  be  looked  upon  as  presumabh' 
rheumatic.  And  when  we  remember  the  danger  of 
untreated  rheumatism  in  a  child,  and  the  heart-disease 

T 


290  PATHOLOGY  AND  TREATMENT  OF  CHOREA 

which  it  so  frequently  causes,  we  see  how  great  an 
injury  one  may  do  to  a  child  by  neglecting  a  slight 
chorea.  Many  a  mitral  stenosis  in  later  life,  with  its 
distressful  years  and  its  premature  death,  might  have 
been  averted  if  the  practitioner  who  attended  the  case 
of  slight  chorea  in  childhood  had  treated  it  vigorously 
as  rheumatic. 

If,  then,  in  the  majority  of  cases  chorea  means  a 
brain  infected  with  rheumatic  diplococci,  surely  the 
treatment  which  cures  rheumatism  ought  to  cure 
chorea.  Yet  it  is  not  the  general  experience  that 
much  has  been  effected  in  this  way.  May  not  this  be 
because  the  doses  given  have  been  too  small  ?  If  one 
wishes  to  cure  a  cerebral  syphilis,  large  doses  of  iodide 
must  be  employed.  Acting  on  this  idea,  I  have  lately 
given  to  cases  of  acute  chorea  large  and  frequent  doses 
of  sodium  salicylate,  to  which  invariably  has  been 
added  twice  the  amount  of  sodium  bicarbonate.  This 
addition  of  alkali  I  think  of  great  importance,  from 
more  than  one  point  of  view.  In  a  considerable 
number  of  cases  this  treatment  has  produced  a  very 
rapid  improvement.  The  plan  is  certainly  deserving 
of  further  trial  in  acute  chorea.  Success  seems  to 
depend  upon  the  amount  given  daily,  a  further 
improvement  sometimes  following  each  increase  of 
the  dose.  That  the  improvement  is  not  due  merely 
to  the  rest  in  bed,  nursing,  and  feeding,  has  been 
proved  in  some  cases  by  allowing  three  or  four  days 
to    elapse    before     administering    medicine.      Some 


TREATMENT  BY  SODIUM  SALICYLATE    291 

cases  grow  worse  if  left  untreated,  others  improve 
slightly. 

The  dose  of  sodium  salicylate  for  a  child  of  6  to  lO 
years  should  be  at  first  lo  gr.,  with  20  gr.  of  sodium 
bicarbonate.  After  two  or  three  days  the  quantities 
should  be  increased  to  1 5  gr.  and  30  gr.  respectively. 
After  two  or  three  days  more  they  may,  if  necessary 
be  increased  to  20  gr.  and  40  gr.  These  doses  should 
be  given  every  two  hours  during  the  day,  and  every 
four  hours  during  the  night,  ten  doses  in  the  twenty- 
four  hours.  Thus  the  total  amount  of  salicylate  given 
at  first  is  100  gr.  daily,  increased  to  150  gr.,  and 
finally  to  200  gr. 

A  careful  watch  must,  of  course,  be  kept  for  any 
symptoms  of  salicylate  poisoning,  and  especially  for  a 
peculiar  deep  inspiration  simulating  the  "  air-hunger  " 
of  diabetes.  If  this  occurs,  the  medicine  must  be 
immediately  given  up,  for  it  is  a  sign  of  danger.  It 
is,  however,  a  rare  phenomenon.  There  is  some 
reason  for  thinking  that  it  is  really  an  acid  poisoning. 
The  similar  air-hunger  of  commencing  diabetic  coma 
may  sometimes  be  arrested  by  large  and  frequent 
doses  of  alkalies,  and  the  only  fatal  case  of  salicylic 
air-hunger  that  has  come  under  my  own  observation 
had  taken  the  salicylate  without  any  additional  alkali. 
Air-hunger  began  to  show  itself  in  one  case  which  I 
treated  with  aspirin  instead  of  salicylate,  without 
alkalies,  and  disappeared  when  the  drug  was  omitted. 
It  seems  to  me  very  important  that  each  dose  of 


292  PATHOLOGY  AND  TREATMENT  OF  CHOREA 

salicylate  should  be  accompanied  by  twice  as  much 
bicarbonate. 

The  unpleasant  symptoms  sometimes  caused  by 
salicylates  in  adults,  the  deafness  and  noises  in  the 
ears,  the  headache,  the  mental  symptoms  and  delirium, 
are  exceedingly  rare  in  childhood.  Occasionally 
vomiting  is  troublesome,  but  it  may  usually  be  over- 
come by  suspending  the  treatment  for  a  few  hours 
and  then  beginning  again  with  a  smaller  dose,  which 
should  be  gradually  increased.  Pulse-failure  occur- 
ring during  the  employment  of  salicylates,  both  in 
children  and  in  adults,  is  generally  not  due  to  the 
remedy,  but  is  caused  by  an  acute  rheumatic  dilata- 
tion of  the  left  ventricle — a  common,  but  usually 
overlooked,  phenomenon  in  rheumatism.  Careful 
observation  of  the  position  of  the  border  of  the  left 
ventricle,  as  ascertained  by  accurate  light  percussion, 
should  be  made  daily.  As  to  any  general  "  depres- 
sion" from  the  salicylate,  in  children  it  is  usually 
quite  absent ;  indeed,  it  has  been  remarkable  how 
much  brighter  and  more  lively  the  patients  have 
become  during  the  treatment.  It  should  be  added 
that  the  large  doses  of  bicarbonate  do  not  impair 
appetite  or  disturb  digestion  in  rheumatic  children, 
and  that,  in  spite  of  them,  the  urine  often  remains 
acid  for  a  considerable  time.  Albuminuria  is  not 
caused  by  the  treatment  above  advised. 

Every  choreic  child  should,  I  think,  be  kept  for  a 
time    completely  at  rest   in   bed,  however   mild  the 


ACUTE  CHOREA  293 

chorea  may  be.  If  there  is  much  tendency  to  excite- 
ment, restlessness,  or  emotional  attacks,  complete 
isolation  is  very  helpful.  A  cot  with  padded  sides  is 
necessary  in  severe  cases,  and  the  most  careful  and 
efficient  nursing  is  essential.  It  may  be  needful  to 
give  in  such  cases  hypnotic  drugs,  as  chloralamide, 
chloral,  or  bromide,  the  first  night  or  two,  to  secure 
sleep,  but  in  many  cases  these  canl)e  avoided  if  large 
doses  of  salicylate  and  bicarbonate  are  used.  The 
diet  at  first  should  be  of  milk  only. 

In  acute  cases  this  treatment  is  often  very  successful. 
The  time  at  my  disposal  will  not  allow  me  to  give 
details  of  cases,  but  I  will  briefly  mention  one  as  an 
illustration. 

J.  S.,  aged  7  years,  was  admitted  into  St  Mary's 
Hospital  on  3rd  July,  suffering  from  general  chorea  of 
moderate  severity.  She  was  kept  in  bed  for  six  days 
without  any  medicine.  During  this  period  her  chorea 
became  distinctly  worse.  On  9th  July,  the  movements 
being  more  choreic  than  on  her  admission,  15-gr.  doses 
of  sodium  salicylate  with  30  of  bicarbonate  every  two 
hours  during  the  day  and  every  four  hours  during  the 
night,  were  ordered  ;  the  total  daily  dose  being  150-gr. 
of  the  salicylate  and  300  of  the  bicarbonate.  This 
treatment  was  continued  for  six  days.  Some  vomit- 
ing was  caused  by  the  abrupt  introduction  of  very 
large  amounts  of  salicylate,  and  three  or  four  doses 
were  omitted  in  consequence.  On  15th  July,  after  six 
days  of  this  treatment,  the  inspiration  seemed  to  be 
abnormally  deep,  and  the  salicylate  was  stopped  en- 
tirely, while  the  bicarbonate  was  continued.  But 
already  the  choreic  movements  had  very  much  dimin- 

T  2 


294  PATHOLOGY  AND  TREATMENT  OF  CHOREA 

ished.  On  i8th  July  hardly  any  could  be  seen,  and 
on  22nd  July  the  child  was  perfectly  quiet,  except  that 
there  were  very  slight  movements  in  the  fingers. 

It  is  usually  advisable  to  begin  the  treatment  with 
smaller  doses,  which  often  cause  no  vomiting  at  all, 
but  in  this  case  a  large  initial  dose  was  purposely 
employed,  as  a  test,  and  the  result  was  most 
remarkable. 

I  could  give  other  cases  almost  as  striking  as  this, 
and  now  feel  confident  that  this  is  the  most  success- 
ful treatment  for  acute  chorea. 

In  chronic  cases  one  cannot  be  surprised  if  the 
effect  of  this  (or  any  other)  treatment  is  less  certain, 
for  even  though  the  microbes  may  be  destroyed  and 
their  toxin  neutralised,  the  cortical  cells  may  possibly 
remain  for  some  time  in  a  condition  of  irritable  weak- 
ness. It  is  not  always  possible  at  once  to  get  rid  of  an 
effect  by  removing  its  cause.  Where  the  cortical  centres 
have  been  severely  affected,  time  may  be  an  essentia) 
factor  in  their  recovery.  Prolonged  rest  and  the  gradual 
introduction  and  increase  of  the  stimulus  of  voluntary 
action  may  be  necessary.  Yet  even  in  chronic  cases 
I  have  seen  remarkable  benefit.  For  instance,  in  a  case 
treated  recently  by  10  gr.  of  salicylate  and  20  gr.  of 
bicarbonate  every  three  hours,  improvement  to  a  cer- 
tain extent  resulted,  but  not  a  complete  cure.  Large 
doses  of  liquor  arsenicalis  were  given  for  a  few  days, 
but  no  good  result  followed.  Then  the  salicylate  and 
bicarbonate  were  given  again  in  larger  doses,  15  gr. 


CHRONIC  CHOREA  295 

and   30  gr.  respectively,  and    very  soon    the   chorea 
had  ceased  entirely. 

I  do  not  desire  to  discuss  the  use  of  other  drugs 
in  chorea.  Arsenic,  in  large  doses  for  a  short  time, 
sometimes  produces  distinct  improvement,  but  if  its 
use  is  continued  for  more  than  a  week,  there  is 
danger  of  producing  arsenical  neuritis.  Dr  Eustace 
Smith  has  recently  advocated  th-e  employment  of 
large  doses  of  ergot.  Dr  John  Thomson,  of  Edin- 
burgh, tells  me  that  he  has  had  good  results  with 
antipyrin.  I  say  nothing  of  aids  to  convalescence, 
such  as  massage,  the  cold  douche,  and  the  adminis- 
tration of  iron  and  of  other  tonics.  What  I  desire 
to  urge  is,  that  every  case  should  be  looked  upon  as 
presumably  rheumatic,  should  at  first  be  kept  in  bed, 
and  treated  vigorously,  as  for  rheumatism. 

P.S.  (Marck  1904). — Since  the  publication  of  this 
paper,  I  have  had  further  experience  in  the  admin- 
istration of  large  doses  of  sodium  salicylate  in  the 
treatment  of  chorea  and  of  rheumatism.  I  find  that 
in  adults  the  amount  given  may  sometimes  be 
increased  with  advantage  to  400  gr.,  or  even  450  gr., 
daily,  in  ten  doses  (each  dose  accompanied  by  twice 
as  much  sodium  bicarbonate),  and  that  some  cases 
of  recurrent  subacute  rheumatism  cannot  be  cured 
by  smaller  doses.  I  find  also  that,  even  where  the 
first  employment  of  the  salicylate  causes  vomiting, 
tinnitus,  deafness,  headache,  or  delirium,  it  is  almost 


296  PATHOLOGY  AND  TREATMENT  OF  CHOREA 

always  possible  to  accustom  the  patient  to  the  drug 
by  waiting  for  a  few  hours  only,  and  then  giving 
a  smaller  dose.  This  can  usually  be  soon  increased, 
and  quite  large  doses  safely  given  before  long. 

In  choreic  and  rheumatic  children,  I  find  that  after 
a  short  time  300  gr.  of  sodium  salicylate,  and  600  gr. 
of  sodium  bicarbonate  (in  ten  doses)  are  generally 
well  borne,  that  they  rarely  cause  vomiting,  and  that 
no  depression  follows.  There  is  a  marked  improve- 
ment in  brightness  of  expression  and  manner,  and 
also  improved  nutrition. 

But  it  must  be  clearly  understood  that  each  of 
these  large  doses  has  been  invariably  associated  with 
twice  as  much  sodium  bicarbonate — e.g.,  60  gr.  of 
this  drug  with  each  of  the  30-gr.  doses  of  sodium 
salicylate.  Without  this  addition,  there  is  danger  of 
causing  an  acid-poisoning,  the  evidence  of  which  is 
an  "  air-hunger  "  like  that  observed  in  diabetes  ;  and 
this  may  soon  be  followed  by  a  fatal  coma.  I  recently 
saw,  in  consultation,  a  child  suffering  from  slight 
chorea,  who  had  been  treated  with  15-gr.  doses  of 
aspirin,  given  three  times  daily.  After  seven  doses 
(105  gr.  in  two  days)  she  became  comatose.  Large 
doses  of  sodium  bicarbonate  (a  drachm  hourly)  were 
at  once  administered.  When  I  saw  her,  about  twenty- 
four  hours  later,  the  coma  had  quite  passed  away, 
and  she  answered  questions  readily,  but  the  typical 
air-hunger  still  remained.  The  inspirations  were  very 
deep,  and  the  air  filled  both  lungs ;  the  pulmonary 


DOSE   OF   SODIUM   SALICYLATE  297 

regions  were  resonant  everywhere,  and  free  from 
rales.  She  recovered  perfectly.  This  case  proves 
that  aspirin  is  capable  of  producing  the  most 
dangerous  symptoms  of  salicylic  poisoning.  But  in 
the  cases  treated  with  large  doses  of  sodium  sali- 
cylate and  bicarbonate,  no  such  symptoms  have 
been  observed,  though  in  many  of  them  the  large 
doses  have  been  continued  for  two  or  three  weeks. 


INDEX 


Acute  nephritis,  93 

Ainley  Walker  and  Ryffel :  report 
on  the  acid  products  of  rheuma- 
tism, 17 

Air-hunger,  a  symptom  of  salicylic 
poisoning,  lo,  291 

Albumose  of  rheumatism,  18 

Alcohol,  55 

Alkaline  treatment  of  rheumatism, 
18 

Ammonium  carbonate,  55 

Anaemia  of  rheumatism,  18 

Aortic  murmurs  rare  in  children, 
229 

Aphasia  in  chorea,  279 

Appendicitis,  90,  157 

Atropine,  53,  176,  273 

Auricle,  27,  29,  47,  260-264 

Belladonna,  54 

Bleeding,  as  formerly  used  in  pneu- 
monia, 48 

Blisters,  24 

Bronchopneumonia  treated  with 
bleeding  and  ice,  113 

Cardiac  depression  in  rheumatism, 

Cardiac  dilatation,  15,  19,  26,  177, 
192,  210,  219,  220,  224,  238,  241, 
243 


Cardiac  dyspnoea,  189 

Cardiac  percussion,  194-199 

Cardiac  tonics  in  pneumonia,  52 

Carditis,  6,  35 

Chorea,  165,  275 

Chorea  and  rheumatism,  283 

Chorea  often  the  first  symptom  of 

rheumatism,  284 
Chorea  :     possible    non  -  rheumatic 

causes,  289 
Chorea,  sodium  salicylate  in,  290, 296 
Chorea :     general    treatment,    292, 

295 
Clubbing,  108 

Croaking  inspiration  in  infants,  no 
Cyanosis,  103-108 

Degeneration  of  cardiac  muscle, 

233 

Dextrocardiac  -  respirator)'  reflex, 
176,   181 

Diet  in  pneumonia,  49 

Digitalis,  55,  177,  180,  273 

Dilatation  of  left  ventricle  in  rheuma- 
tism, 15,  19,  26,  192,  243;  in 
diphtheria,  19,  238  ;  in  influenza, 
19,  241 

Diphtheria  a  cause  of  sudden  death, 
231 

Double  second  sound,  226 

Dyspnoea  in  pericarditis,  29,  181 


INDEX 


299 


Emotional  storms  in  choreaj  279 
Empyema,    84 ;    difficulties    of    its 

diagnosis,  86 
Endocarditis,  216,  225 

Formic  acid,  a  product  of  the  rheu- 
matic diplococcus,  17 

General  paralysis  of  the  insane, 
with  mainly  physical  symptom^s, 
169 

Heart,  inflammation  of,  6 ;  its 
causes,  7,  8  ;  malformation  of, 
loi  ;  of  the  child,  252  ;  examina- 
tion of,  254 

ICEBAG,  as  a  therapeutic  agent,  148  ; 
method  of  application,  30-32  ;  pre- 
cautions, 25,  32  ;  in  pericarditis, 
24,  30,  155,  168  ;  in  pneumonia, 
55,  115,  120,  150,  152;  sites  of 
application,  60;  effects,  59,  65; 
in  acute  pleurisy,  87,  155  ;  in 
serous  pleural  effusion,  88 ;  in 
acute  local  pulmonary  tubercu- 
losis, 89  ;  in  acute  laryngitis,  89  ; 
in  local  peritonitis  over  gastric 
ulcer,  90  ;  in  appendicitis,  91,  92, 
157  ;  in  acute  nephritis,  95  ;  in 
sciatica,  159 

Larynx  from  an  infant  with  croak- 
ing inspiration,  no 

Leeches.  24,  29,  30,  45,  47,  77,  79, 
80,  120,  177,  261,  273 

Left  ventricle,  15,  19,  43,  197,  238, 
241,  243,  265-270 

Local  applications  in  pericarditis,  24 

Malformed  heart,  with  transposi- 


tion of  the  aorta  and  pulmonary 

artery,  loi 
Malformed  heart :  murmurs,  259 
Mental  dullness  in  chorea,  280 
Mitral  stenosis,  paroxysmal  dyspncca 

in,  53,  174,  186 
Mitral    stenosis    rare    in    children, 

229 
Motor    cortex    excited    in    chorea, 

277 

Nephritis,  93 ;  suppression  of  urine 
in,  95  ;  cases  treated  by  the  ice- 
bag,  96,  97,  98 

Otitis  and  meningitis,  125 
Oxygen,  54,  79 

Paracentesis  tympani,  126 

Paroxysmal  dyspnoea  in  mitral 
stenosis,  53,  174,  186 

Percussion,  21,  28,  57,  237,  256 

Pericarditis,  causes  of,  8  ;  frequency 
of,  217 ;  local  treatment,  30  ; 
effects  of  treatment,  34  ;  in  chorea, 
165  ;  cardiac  dilatation  in,  167, 
193,  210;  dyspnoea  in,  29,  181  ; 
liable  to  be  mistaken  for  aortic 
disease,  230  ;  suppurative,  35 

Pericardial  effusion,  26,  27,  218, 
223 

Physical  examination,  57,  235,  254 

Pleurisy,  87,  155 

Pleural  effusion,  88 

Pneumococcus,  a  cause  of  suppura- 
tive pericarditis,  8  ;  affected  by  its 
environment,  61-64,  I54i  bacterio- 
logy of,  61-64  ;  experimental 
results,  67-69  ;  rapid  multiplica- 
tion, 75 

Pneumonia,  a   pneumococcal   inva- 


300 


INDEX 


sion,  38  ;  earliest  signs,  71  ;  cases 
of  arrest,  73,  74;  crisis,  83; 
mortality,  40  ;  not  chiefly  a 
blood-disease,  66  ;  outline  plan 
of  treatment,  70  ;  the  most  im- 
portant part  of  its  treatment,  48  ; 
cases  treated  with  ice,  73,  74,  115, 
120,  150,  152 

Poynton  and  Paine  :  the  rheumatic 
diplococcus,  7,  249,  271,  285 

Precordial  dullness,  26,  28 

Presystolic  apex-murmur  :  earliest 
stage,  226-228 

Presystolic  apex-murmur  due  to 
aortic  regurgitation,  132,  140,  146 

Prognosis  in  rheumatism  of  chil- 
dren, 230 

Pulmonary  embolism,  183 

Rheumatic  diplococcus,  7,  249, 
271,  286;  destructive  of  red  cor- 
puscles, 18 

Rheumatism,  a  microbic  process, 
7,  213,  249  ;  cardiac  dilatation  in, 
15,  19,  26,  192,  243  ;  signs  often 
slight,  247 ;  virulence  in  early 
life,  215,  220 

Right  auricle,  27,  29,  47,  260-264 


Right  heart  in  pneumonia,  43,  44 
Right-heart  misery,  45 
Right-ventricle  murmur  in  children, 
264 

Sleep  in  pneumonia,  50,  261 
Sodium  salicylate,  truly  anti- 
rheumatic, 9,  272  ;  amount  to 
be  given,  10,  295  ;  in  chorea,  22. 
291,  296  ;  in  chronic  rheumatism, 
22  ;  not  a  cardiac  depressant,  14, 
272,  292  ;  poisonous  effects,  10,  295 

Spasmodic     dyspnoea     in     mitral 

stenosis,   53,   174,   186 
Strychnine,  30,  52,  79 
Sudden  death  after  diphtheria,  231 
Suppurative  pericarditis,  35 

Tendency  to  spread  in  pneumonia, 

58 
Tubercle  spreading  from  bronchial 

glands  into  lung,  86 

Venesection,  29,  30,  47,  79,  81, 

114,177,248 
Vomiting,  a  sign  of  acute  cardiac 

dilatation,  239,  246 


PRINTED   BV   OLIVER  AND  BOYD,  TWBEDDALB  COURT,   EDINBURGH. 


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SUBJECT  INDEX, 


Gould's  Medical  Dictionaries, 
Morris'  Anatomy,  =  =  = 
Compends  for  Students,  - 


Pages  12,  13 
Page  4 
Page  27 


BUBJICT.  PA«B 

Alimentary  Canal  (sec  Sur- 
gery)     24 

Anatomy 7 

Anesthetics    18,  19 

Autopsies  (see  Pathology)  20 

Bacteriology    8 

Bandaging  (see  Surgery) .  .  24 

Blood,  Examination  of .  . .  8 

Brain 8 

Bright's  Disease 26 

Chemistry.     Physics    ....  9 

Children,  Diseases  of 11 

CliraatoloKy   19 

Clinical   Charts 25 

Compends 27 

Consumption  (see  Lungs) .  16 

Cyclopedia  of  Medicine ...  13 

Dentistry 11 

Diabetes(8eeUrin.  Organs)  25 

Diagnosis 11 

Diagrams  (see  Anatomy),  8 

Dictionaries,   Cyclopedias.  12 

Diet  and  Food 13 

Disinfection 16 

Dissectors 7 

Ear    14 

Electricity    14 

Embryology 7 

Emergencies 24 

Eye   14 

Fevers 15 

Food 13 

Formularies 21 

Gynecology    15 

Hay  Fever 25 

Heart    15 

Histology   15 

Hydrotherapy 19 

Hygiene    16 

Hypnotism 8 

Insanity 8 

Intestines 23 

Latin,  Medical  (see  Phar- 
macy)    21 

Life  Insurance 19 

Lungs 16 

Massage    17 

Materia  Medica 17 

Mechanotherapy 17 


SUBJECT.  PAoa 

Medical -Turisprudence ... .    18 

Mental  Theraijeutics 8 

Microscopy 18 

Milk    8,10 

Miscellaneous 18 

Nervous  Diseases 19 

Nose    25 

Nursing 20 

Obstetrics 20 

Ophthalmology 14 

Organotherapy    18 

Osteology  (see  Anatomy).      7 

Pathology 20 

Pharmacy 21 

Physical  Diagnosis 11 

Physical  Training 17 

Physiology 22 

Pneumotherapy 19 

Poisons  (see  Toxicology)  . .    18 

Practice  of  Medicine 22 

Prescription  Books  (Phar- 
macy)        21 

Refraction  (see  Eye) 14 

Rest    19 

Sanitary  Science »3i    16 

Serum-Therapy 17 

Skin 23 

Spectacles  (see  Eye) .....    14 
Spine    (see    Nervous    Dis- 
eases)       19 

Stomach 23 

Students'   Compends 27 

Surgery  and  Surgical  Dis- 
eases       24 

Technological  Books .....     9 

Temperature  Charts 25 

Therapeutics    17 

Throat    25 

Toxicology 18 

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U.  S.  Pharmacopoeia 22 

Urinary  Organs 25 

Urine 25 

Venereal  Diseases 26 

Veterinary  Medicine 26 

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Water  Analysis 16 

Women,  Diseases  of 15 


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WILLIAMS.  Bacteriology.  A  Manual  for  Students.  99  Illus- 
trations.    3d  Edition,  Revised.  $1.50 

BLOOD,  Examination  of. 

DA  COSTA.  Clinical  Hematology.  A  Practical  Guide  to  the 
Examination  of  the  Blood,  with  Reference  to  Diagnosis.  Six 
Colored  Plates  and  48  other  Illus.       Cloth,  $5.00 ;  Sheep,  $6.00 

BRAIN  AND  INSANITY  (see  also 
Nervous  Diseases.) 

BARR.     Mental  Defectives.     Illustrated.  In  Press. 

BLACKBURN.     A  Manual  of  Autopsies.     Designed  for  the  Us* 

of  Hospitals  for  the  Insane.     Illustrated.  $1.25 

CHASE.     General  Paresis.     Illustrated.  $1.75 

DERCUM.     Mental  Therapeutics,  Rest,  Suggestion.     See  Cohen, 

Physiologic  Therapeutics,  page  17. 
GORDINIER.     The  Gross  and  Minute  Anatomy  of  the  Central 

Nervous  System.      With  full-page  and  other  Illus.         $6.00 


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IRELAlfD.    The  Mental  Affections  of  Children.     2d  Ed.     $4.00 
LEWIS    (BEVAN).     Mental     Diseases.      A    Text-Book    having 
Special  Reference  to  the  Pathological  Aspects  of  Insanity.    26 
Tvithographio  Plates  and  other  Illustrations.     2d  Ed.      $7.00 
MANN.     Manual  of  Psychological  Medicine.  $3.00 

PERSHING.      Diagnosis  of  Nervous  and  Mental  Disease.     Illus- 
trated. $1.25 
REGIS.     Mental  Medicine.     By  H.  M.  Bani«8t«r,  m.b.    $2.00 
STEARNS.     Mental  Diseases.     With  a  Digest  of  La^ws  Relating 
to  Care  of  Insane.     Illustrated.         Cloth,  $2.7.5;  Sheep,  $3.25 
TUKE.     Dictionary    of    Psychological    Medicine.     Giving    the 
Definition    of    Terms    and    the    Symptoms,    Pathology,    and 
Treatment  of  Mental  Disorders.     Two  volumes.               $10.00 
WOOD,  H.  C.     Brain  and  Overwork.  .40 


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ucts Employed  in  the  Arts,  Manufactures,  Medicine,  etc., 
with  Concise  Methods  for  the  Detection  of  Impurities,  Adul- 
terations, etc.     8vo. 

Vol.  I.     Alcohols,  Neutral  Alcoholic  Derivatives,  etc..  Ethers 
Vegetable  Acids,  Starch,  Sugars,  etc.     3d  Edition.     $4.50 
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etc.     3d  Edition.  $3.50 

Vol.  II,  Part  II.  Hydrocarbons,  Mineral  Oils,  Lubricants, 
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etc.     3d  Edition.  $3.50 

Vol.  II,  Part  III.  Terpenes,  Essential  Oils,  Resins,  Camphors, 
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Edition,  Enlarged   and   RewTitten.      Illustrated.  $4,50 

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BARTLEY.  Clinical  Chemistry.  The  Examination  of  Feces, 
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BLOXAM.  Chemistry,  Inorganic  and  Organic.  With  Experi- 
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BUNGE.  Physiologic  and  Pathologic  Chemistry.  From  the 
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CALDWELL.  Elements  of  Qualitative  and  Quantitative  Chem- 
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10  SUBJECT  CATALOGUE. 

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CLOWES  AND  COLEMAN.  Qxxantitative  Analysis.  6th  Edi- 
tion.    125  Illuatrations.  S3.50 

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Numerous  Tables  and  56  Illustrations.  $1.00 

GARDNER.  The  Brewer,  DistiUer,  and  Wine  Manufacturer. 
Illustrated.  $1.50 

GRAY.  Physics.  Volume  I.  Dynamics  and  Properties  of 
Matter.     350  Illustrations.  $4.60 

GROVES  AND  THORP.     Chemical  Technology.     The  Applica- 
tion of  Chemistry  to  the  Arts  and  Manufactures. 
Vol.  I.  Fuel  and  its  Applications.     607  Illustrations  and  4 
Plates.  Cloth,  $5.00;  i  Mor.,  $6.50 

Vol.11.    Lighting.     Illustrated.        Cloth,  $4.00;  i  Mor.,  $5.50 
Vol.  III.  Gas  Lighting.  Cloth,  $3.50;  i  Mor.,  $4.50 

Vol.  IV.  Electric  Lighting.     Photometry. 

Cloth.  $3.50:  i  Mor.,  $4.50 

HEUSLER.     The  Chemistry  of  the  Terpenes.  $4.00 

HOLLAND.  The  Urine,  the  Gastric  Contents,  the  Common 
Poisons,  and  the  Milk.  Memoranda,  Chemical  and  Micro- 
scopical, for  Laboratory  Use.     6th  Ed.     Illustrated.       $1.00 

LEFFMANN,  Compend  of  Medical  Chemistry,  Inorganic  and 
Organic.     4th  Edition,  Revised.       $1.00;  Interleaved,  SI. 25 

LEFFMANN.  Analysis  of  Milk  and  Milk  Products.  2d  Edition, 
Enlarged.     Illustrated.  $1.25 

LEFFMANN.  Water  Analysis.  For  Sanitary  and  Technic  Pur- 
poses.    Illustrated,     oth  Edition.     Just  Ready.  $1.25 

LEFFMANN.  Structural  Formula.  Including  180  Structiu-al 
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LEFFMANN  AND  BEAM.  Select  Methods  in  Food  Analysis. 
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MUIR.     Elements  of  Chemistry.  In  Press. 

MtJTER.  Practical  and  Analytical  Chemistry.  3d  American 
from  the  Ninth  English  Edition.  Revised  to  meet  the  re- 
quirements of  American  Students.     56  Illustrations.         $1.25 

OETTEL.     Exercises  in  Electro-Chemistry.    Illustrated.  .75 

OETTEL.     Electro-Chemical  Experiments,     Illustrated.  ,75 

RICHTER.  Inorganic  Chemistry.  6th  American  from  10th 
Gorman  Edition.  Authorized  translation  by  Edqar  F.  Smith, 
M.A  ,  PH.D.     89  Illustrations  and  a  Colored  Plate.  $1.75 

RICHTER.  Organic  Chemistry.  3d  American  Edition,  trans- 
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Vol.    I.  Aliphatic  Series.     625  pages.  $3.00 

Vol.  II.  Carbocyclic  Series.     671  pages.  $3.00 

ROCKWOOD.  Chemical  Analysis  for  Students  of  Medicine, 
Dentistry,  and  Pharmacy.     Illustrated.  $1.60 

SMITH.     Electro-Chemical  Analysis.     3d  Ed.  39  Illus.     $1.60 

SMITH  AND  KELLER.  Experknents.  Arranged  for  Students 
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SUTTON.  Volumetric  Analysis.  A  Systematic  Handbook  for 
the  <juautitative  Estimation  of  Chemical  Substances  by 
Measure,  Applied  to  Liquids,  Solids,  and  Gases.  9th  Edition, 
Revised.     112  Illustrations,  Nearly  Ready. 

TRAUBE.     Physico-chemical  Methods,    97  Illustrations.    $1.60 


MEDICAL  BOOKS.  11 


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ULZER    AND    FRAEWKEL.        Chemical    Technical    Analyiii. 

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Illufltrated.  $1.60 

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CHILDREN. 

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HATFIELD.  Compend  of  Diseases  of  Children.  With  a 
Colored  Plate.     3d  Ed.  $1.00;  Interleaved.  SI. 25 

IRELAND.  Tha  Mental  Affections  of  Children.  Idiocy,  Im- 
becility, Insanity,  etc.     2d  Edition.  $4.00 

POWER.  Surgical  Diseases  of  Children  and  their  Treatment 
by  Modern  Methods.     Illustrated.  $2.50 

STARR.  The  Digestive  Organs  in  Childhood.  The  Disease*  of 
the  Digestive  Orgrans  in  Infancy  and  Childhood.  3d  Edition, 
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STARR.  Hygiene  of  the  Nursery.  Including  the  General  Regi- 
men and  Feeding  of  Infants  and  Children,  and  the  Domestic 
Management  of  the  Ordinary  Emergencies  of  Early  Life, 
Massage,  etc.     6th  Edition.     25  Illu«trations.  $1.00 

SMITH.     Wasting  Diseases  of  Children.     6th  Edition.  $2.00 

TAYLOR  AND  WELLS.  The  Diseases  of  Children.  2d  Edition. 
Revised  and  Enlarged.     Jllustrated.     8vo.  S4.50 

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BERRY.     Surgical  Diagnosis.  In  Press. 

DA  COSTA.  Clinical  Hematology.  A  Practical  Guide  to  Exam- 
ination of  Blood,  with  Reference  to  Diagnosis.  6  Colored 
Plates,  4S  other  Illustrations.  Cloth,  $5.00;  Sheep,  $6.00 

DOUGLAS.  Surgical  Diseases  of  Abdomen,  with  Reference  to 
Diagnosis.     20  Full-Page  Plates.     Cloth,  $7.00  ;  Sheep,  $8.00 

EMERY.  Bacteriological  Diagnosis.  2  Colored  Plates  and  32 
other  Illustrations.  $1.50 

MEMMINGER.    Diagnosis  by  the  Urine.    2d  Ed.    24  Illua.    $1.00 

PERSHING.  Diagnosis  of  Nervous  and  Mental  Diseases. 
Illustrated.  $1.25 

STEELL.     Physical  Signs  of  Pulmonary  Disease.  $1.25 

TYSON.  Handbook  of  Physical  Diagnosis.  For  Students  and 
Physicians.  By  the  Professor  of  Clinical  Medicine  in  the  Uni- 
versity of  Pennsylvania.  Illus.  4th  Ed.,  Improved  and  En- 
larged.    With  2  Colored  and  55  other  Illustrations.  $1.50 

DENTISTRY. 

Special  Catalogue  of  Dental  Books  itent  free  upon  application. 
BARRETT.     Dental    Surgery    for    General    Practitioners    and 
Students  of  Medicine  and  Dentistry.     Extraction  of  Teeth, 
eta.     3d  Edition.     Illustrated.  $1.00 


12  SUBJECT  CATALOGUE. 

BROOMELL.  Anatomy  and  Histology  of  the  Human  Mouth 
and  Teeth.  Second  Edition,  Revised  and  Enlarijed.  337 
handsome  Illustrations.  Cloth,  $4.50;  Leather,  $5.50 

FILLEBROWN.      Operative  Dentistry.    Illu«trated.  $2.25 

GORGAS,  Dental  Medicine.  A  Manual  of  Materia  Medica  and 
Therapeutics.     7th  Edition.  Cloth,  $4.00;  Sheep,$5.00 

GORGAS.  Questions  and  Answers  for  the  Dental  Student, 
Embracing  all  the  subjects  in  the  Curriculum  of  the  Dental 
Student.     Octavo.  $6.00 

HARRIS.  Principles  and  Practice  of  Dentistrv.  Including 
Anatomy,  Physiology,  Pathology,  Therapeutics,  Dental  Sur- 
gery, and  Mechanism.  13th  Edition.  Revised  by  F.  J.  S. 
GoRQAs,  M.D.,  D.D.8.     1250  Illus.    Cloth,  $6.00 ;  Leather,  $7.00 

HARRIS.  Dictionary  of  Dentistry.  Including  Definitions  of  Such 
Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain  to  the 
Art  and  Practice  of  Dentistry.  6th  Edition,  Revised  and 
Enlarged  by  Fbrdinand  J.  S.  Goroab,  m.b.,  ».d.s. 

Cloth,  $5.00;  Leather,  $6.00 
RICHARDSON.     Mechanical  Dentistry.      7th   Edition.     Thor- 
oughly Revised  and  Enlarged  by  Dr.  Gho.  W.  Warrbn.  691 
Illustrations.  Cloth,  $5.00;' Leather,  $6.00 

SMITH.     Dental  MetaUurgy.    2d  Edition.    Illustrated.         $2.00 
TAFT.     Index  of  Dental  Periodical  Literatiu-e.  $2.00 

TOMES.  Dental  Anatomy.  263  Illustrations.     6th  Ed.  In  Press. 
TOMES.     Dental  Surgery.     4th  Edition.     289  Illus.  $4.00 

WARREN.  Compend  of  Dental  Pathology  and  Dental  Medicine. 
With  a  Chapter  on  Emergencies.    4th  Edition.     Illustrated. 

$1.00;  Interleaved,  $1.25 

WARREN.     Dental  Prosthesis  and  MetaUurgy.    129  Illus.     New 

Edition,  Enlarged  and  Revised.  Nearly  Ready. 

WHITE.     The  Mouth  and  Teeth.     Illustrated.  .40 

DICTIONARIES.     CYCLOPEDIAS. 

GOULD.  The  Illustrated  Dictionary  of  Medicine,  Biology,  and 
Allied  Sciences.  Being  an  Exhaustive  Lexicon  of  Medicine  and 
those  Sciences  Collateral  to  it:  Biology  (Zoology  and  Botany), 
Chemistry,  Dentistry,  Pharmacology,  Microscopy,  etc.,  with 
many  useful  lables  and  numerous  fine  Illustrations.  1633 
pages.     Fifth  Edition. 

Sheep  or  Half  Morocco.  $10.00:  with  Thumb  Index,  $11.00 
Half  Russia,  Thumb  Index,  $12.00 
GOULD.  The  Medical  Student's  Dictionary,  nth  Edition.  Il- 
lustrated. Including  those  Words  and  Phrases  generally  used 
in  Medicine,  with  their  Proper  Pronunciation  and  Definition, 
Based  on  Recent  Medical  Literature.  With  Table  of  Epo- 
nymic  Terms  and  Tests  and  Tables  of  the  Bacilli,  Micrococci, 
Mineral  Springs,  etc.,  of  the  Arteries,  Muscles,  Nerves,  Ganglia, 
Plexuses,  etc.  Eleventh  Edition.  Enlarged  and  illustrated 
with  a  large  number  of  Engravings.     840  pages. 

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MEDICAL  BOOKS.  13 


GOULD.  The  Pocket  Pronouncing  Medical  Lexicon.  4th  Edi- 
tion. (30,000  Medical  Words  Pronounced  and  Defined.)  Con- 
taining all  the  Words,  their  Definition  and  Pronunciation, 
that  the  Medical,  Dental,  or  Pharmaceutical  Student  Gener- 
ally Comes  in  Contact  with;  also  Elaborate  Tables  of  Epo- 
nymic  Terms,  Arteries,  Muscles,  Nerves,  Bacilli,  etc.,  etc.,  a 
Dose  List  in  both  English  and  Metric  Systeme,  etc..  Arranged 
in  a  Most  Convenient  Form  for  Reference  and  Memorieing. 
Fourth  Edition,  Revised  and  Enlarged.  838  pages. 
Full  Limp  Leather,  Gilt  Edges,  $1.00;  Thumb  Index,  $1.25 
165,000  Copies  of  Gould's  Dictionaries  have  been  sold. 

GOULD  AND  PYLE.  Cyclopedia  of  Practical  Medicine  and 
Surgery.  Seventy-two  Special  Contributors.  Illustrated.  One 
Volume.  A  Concise  Reference  Handbook  of  Medicine,  Sur- 
gery, Obstetrics,  Mat«ria  Aledica,  Therapeutics,  and  the  Vari- 
ous Specialties,  with  Particular  Reference  to  Diagnosis  and 
Treatment.  Compiled  under  the  Editorial  Supervision  of 
Gkorob  M.  Gould,  m.d.,  Author  of  "An  Illustrated  Dictionary 
of  Medicine,"  etc.;  and  Waltbr  L.  Ptlb,  m.d..  Assistant 
Surgeon  Wills  Eye  Hospital;  formerly  Editor  "International 
Metfical  Magaaine,"  etc.,  and  Seventy-two  Special  Contribu- 
tors. With  many  Illustrations.  Large  Square  8vo,  to  corre- 
spond with  Gould's  "Illustrated  Dictionary." 
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GOULD  ATTD  PYLE.  Pocket  Cyclopedia  of  Medicine  and  Sur- 
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"Gould's  Pocket  Dictionary." 

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HARRIS.  Dictionary  of  Dentistry.  Including  Definitions  of 
Such  Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain 
to  the  Art  and  Practice  of  Dentistry.  6th  Edition,  Revised 
and  Enlarged  by  Ferdinand  J.  S.  Gorqas,  m.d.,  d.d.s. 

Cloth,  $5.00;  Leather,  $6.00 

LONGLEY.     Pocket  Medical  Dictionary.  Cloth,  .75 

TREVES  AND  LANG.     German-EngUsh  Medical  Dictionary. 

Half  Calf,  $3.25 

DIET  AND  FOOD, 

ALLEN.  Proteids  and  Albuminous  Principles.  An  analytical 
Study  of  Food  Products.     2d  Edition.  $4.50 

BURNETT.  Foods  and  Dietaries.  A  Manual  of  Clinical  Diet- 
etics, with  Diet  Lists  for  Various  Diseases,  etc.     3d  Ed.     $1.50 

DAVIS.  Dietotherapy.  Food  in  Health  and  Disease.  With 
Tables  of  Dietaries,  Relative  Value  of  Foods,  etc.  See  Cohen, 
Physiologic  TherapeiUics,  page  17. 

GREENISH.  Microscopical  Examination  of  Foods  and  Drugs. 
Illustrated.  $3.50 

HAIG.  Diet  and  Food.  Considered  in  Relation  to  Strength  and 
Power  of  Endvirance.     4th  Edition.  $1.00 

LEFPMANN.  Select  Methods  in  Food  Analysis.  2d  Edition. 
Illustrated.  In  Press. 


14  SUBJECT  CATALOGUE. 

EAR  (see  also  Throat  and  Nose). 

BURNETT.     Hearing  and  How  to  Keep  It.     Illustrated.  .40 

HOVELL.  Diseases  of  the  Ear  and  Naso-Pharyrtr.  Including 
Anatomy  and  Phj'siology  of  the  Organ,  together  with  the 
Treatment  of  the  Affections  of  the  Nose  and  Pharynx  which 
Conduce  to  Aural  Disease.  128  Illustrations.  2d  Ed.  $5.50 
PRITCHARD.  Diseases  of  the  Ear.  4th  Edition,  Enlarged. 
Many  Illustrations  and  Formula.  In  Pr*»*. 

ELECTRICITY. 

BIGELOW.     Plain  Talks  on  Medical  Electricity  and  Batteries. 

With  a  Therapeutic  Index  and  a  Glossary.     43  Illustrations. 

2d  Edition.  $1.00 

HEDLEY.     Therapeutic  Electricity  and  Practical  Muscle  Testing. 

99  Illustrations.  $2.50 

JACOBY.     Electrotherapy.    2  volumes.    Illustrated.    See  Cohen, 

Physiologic  Therapeutics,  page  17. 
JONES.     Medical  Electricity.     3d  Edition.     117  Ulus.         $3.00 

EYE. 

A  Special  Circular  of  Books  on  the  Eye  sent  free  upon  application. 

DARIER.     Ocular  Therapeutics.     Just  Ready.  $3.00 

BONDERS.  The  Nature  and  Consequences  of  Anomalies  of 
Refraction.     With  Portrait  and  Illus.  Half  Morocco,  $1.25 

FICK.  Diseases  of  the  Eye  and  Ophthalmoscopy.  Translated 
by  A.  B.  Halb,  M.D.      157  lUus.     Cloth,  $4.50;    Sheep,  $5.50 

GOULD  AND  PYLE.  Compend  of  Diseases  of  the  Eye  and  Re- 
fraction. Including  Treatment  and  Operations,  and  a  Section 
on  Local  Therapeutics.  With  Formulae,  Useful  Tables,  a 
Glossary,  and  111  Illus.,  several  of  which  are  in  colors.  2d 
Edition,  Revi.sed.  Cloth,  $1.00;  Interleaved,  SI. 25 

GOWERS.     Ophthalmoscopy.     4th  Edition.     Illus.      In  Press. 

GREEFF.  The  Microscopic  Examination  of  the  Eye.  Illu»- 
trated.  $1.25 

HARLAN.     Eyesight,  and  How  to  Care  for  It.     Illus.  .40 

HARTRIDGE.  On  the  Ophthalmoscope.  4th  Edition.  With 
4  Colored  Plates  and  68  Wood-cuts.  $1.60 

HARTRIDGE.  Refraction.  104  Illustrations  and  Test  Types. 
12th  Edition,  Enlarged.  ^  $1.60 

HANSELL  AND  SWEET.  Treatise  on  Diseases  of  the  Eye. 
With  253  Illustrations.  $4.00 

HANSELL  AND  REBER.  Muscular  Anomalies  of  the  Eye. 
Illustrrtted.  $1.60 

HENDERSON.     Notes  on  the  Eye.     138  Illus.     3d  Ed.        $1.60 

JENNINGS.  Manual  of  Ophthamioscopy.  95  Illustrations  and 
1  Colored  Plate.  $1.60 

MORTON.  Refraction  of  the  Eye.  Its  Diagnosij  and  the  Cor- 
rection of  its  Errors.      7th  Elition.  In  Press 

OHLEMANN.  Ocular  Therapeutics.  Authorised  TransUtion, 
and  Edited  by  Du.  Cuarlbs  A.  Oliybb.  $1.75 


MEDICAL  BOOKS  15 


PARSONS.  Elementary  Ophthalmic  Optic*.  With  Diagram- 
mAtio  Illustrationa  $2  00 

PHILLIPS.  Spectacles  and  Eyeglasses.  Their  Prescription 
and  Adjustment.     3d  Edition.     .52  Illustrations.  $1.00 

SWANZY.  Diseases  of  the  Eye  and  Their  Treatment.  8th 
Edition,  Revised  and  Enlarged.  168  Illustrations.  1  Plain 
Plate   and  a  Zephyr  Test  Card.  $2.50 

THORINGTON.  Retinoscopy.  4th  Edition,  Carefully  Revised. 
Illustrated.  $1.00 

THORINGTON.  Refraction  and  How  to  Refract.  200  Illustra- 
tions, 13  of  which  are  colored.     2d  Edition.  $1.50 

WALKER.  Studen*'  Aid  jn  Ophthalmology.  Colored  Plate 
and  40  other  Illustrations  and  a  Glossary.-  $1.50 

WORTH.     Squint :    Its  Causes,  Pathology,  Treatment.        $2.00 

WRIGHT.  Ophthalmology.  2d  Edition,  Revised  and  Enlarged. 
117  Illustrations  and  a  Glossary.  $3.00 

FEVERS. 

GOODALL  AND  WASHBOURN.     Fevers  and  Their  Treatment. 

Illustrated.  $3.00 

WILCOX.     Fever  Nursing.     Just  Ready.  $1.00 

GYNECOLOGY. 

BYFORD  (H.  T.).  Manual  of  Gynecology.  3d  Edition,  Revised 
and  Enlarged.     363  Illustrations.  $3.00;  Sheep,  $3.50 

FULLERTON.  Surgical  Nursing.  3d  Edition,  Revised  and 
Enlarged.     69  Illustrationa.  $1.00 

GALABIN.  Diseases  of  Women.  Sixth  Edition.  By  Alfred 
Lewis  Galabin,  m.a.,  m.d.,  f.r.c.p.  6th  Edition,  Revised 
and  Enlarged.     284  Illustrations.     Octavo.  Cloth,  $5.00 

LEWERS.     Diseases  of  Women.     146  Illus.     5th  Ed.  $2.50 

MONTGOMERY.  Practical  Gynecology.  A  Complete  Sys- 
tematic Text-Book.  2d  Edition,  Revised  and  Enlarged. 
With  539  Illus.  Cloth,  $5.00;  Leather,  $6.00 

ROBERTS.  Gynecological  Pathology.  With  127  Full-page 
Plates  containing  161  Figures.  $6.00 

WELLS.  Compend  of  Gynecology.  145  IDustrations.  3d  Edition, 
Revised  and  Enlarged.  $1.00;  Interleaved,  SI. 25 

HEART. 

THORNE.  The  Schott  Methods  of  the  Treatment  of  Chronic 
Heart  Disease.     Fourth  Edition.     Illustrated.  $2.00 

HISTOLOGY. 

GUSHING.  Compend  of  Histology.  By  H.  H.  Cubhino,  m.d., 
Demonstrator  of  Histology,  Jefferson  Medical  College,  Phila- 
delphia.    Illus.     Ntarly  Ready.  $1.00;  Interleaved,  $1.25 

LAZARUS-BARLOW.  Pathological  Anatomy  and  Hiitology, 
Dluatrated.  $6.60 


16  SUBJECT  CATALOGUE. 

STIRLING.  Outlines  of  Practical  HiBtology.  368  Illustrations. 
2d  Edition,  Revised  and  Enlarged.     With  new  Illus.         $2.00 

STOHR.  Histology  and  Microscopical  Anatomy.  Edited  by 
A.  ScHAPBR,  M.D.,  University  of  Breslau,  formerly  Demon- 
strator of  Histology,  Harvard  Medical  School.  Fifth  Amer- 
ican from  10th  German  Edition,  Revised  and  Enlarged.  353 
Illustrations.  $3.00 

HYGIENE. 

CANFIELD.  Hygfiene  of  the  Sick-Room.  A  Book  for  Nurses 
and  Others.  Being  a  Brief  Consideration  of  Asepsis,  Anti- 
■>epsis,  Disinfection,  Bacteriology,  Immunity,  Heating,  Venti- 
lation, etc.  $1.25 

CONN.     Agricultural  Bacteriology.     Illustrated.  $2.50 

CONN.     Bacteriology  of  Milk  and  Milk  Products.     Illus.     $1.26 

COPLIN.  Practical  Hygiene.  A  Complete  American  Text- 
Book.     138  Illustrations.     New  Edition.  Preparing. 

HARTSHORNE.     Our  Homes.     Illustrated.  .40 

KENWOOD.  PubUc  Health  Laboratory  Work.  116  Illustra- 
tions and  3  Plates.  $2.00 

LEFFMANN.  Select  Methods  in  Food  Analysis.  53  Illustra- 
tions and  4  Plates.     2d  Edition.  In  Press. 

LEFFMANN.  Examination  of  Water  for  Sanitary  and  Technical 
Purposes.     5th  Edition.     Illustrated.      Just  Ready.         $1.25 

LEFFMANN.  Analysis  of  Milk  and  Milk  Products.  Illustrated. 
Second  Edition.  $1.25 

LINCOLN.     School  and  Industrial  Hygiene.  .40 

McFARLAND.  Prophylaxis  and  Personal  Hygiene.  Care  of 
the  Sick,     See  Cohen,  Physiologic  Therapeutics,  page  17. 

N OTTER.  The  Theory  and  Practice  of  Hygiene.  15  Plates  and 
138  other  Illustrations.     8vo.     2d  Edition.  $7.00 

PARKES  AND  KENWOOD.  Hygiene  and  PubUc  Health.  2d 
Edition,  Enlarged.     Illustrated.  $3.00 

ROSENAU.     Disinfection  and  Disinfectants.     Illus.  $2.00 

STARR.  The  Hygiene  of  the  Nursery.  Including  the  Geaeral 
Regimen  and  Feeding  of  Infants  and  Children,  and  the  Domes- 
tic Management  of  the  Ordinary  Emergencies  of  Early  Life, 
Massage,  etc.     6th  Edition.     25  Illustrations.  $1.00 

STEVENSON  AND  MURPHY.  A  Treatise  on  Hygiene.  By 
Various  Authors.     In  three  octavo  volumes.     Illustrated. 

Vol.  I,  $6.00;  Vol.  II,  $6.00;  Vol.  IH,  $5.00 

THRESH.     Water  and  Water  SuppUes.     3d  Edition.  $2.00 

THRESH.    Examination  of  Water  and  Water  Supplies.   In  Press. 

WILSON.  Handbook  of  Hygiene  and  Sanitary  Science.  With 
Illustrations.     8th  Edition,  $3.00 

WEYL.  Sanitary  Relations  of  the  Coal- Tar  Colors.  Authorised 
Translation  by  Hbnkt  Lkftmann,  m.d.,  ph.d.  $1.25 

LUNGS  AND  PLEURA. 

KNOPF.    Pulmonary  Tuberculosis.     Its  Modern  Prophylaxis  and 

Treatment  in  Special  Institutions  and  at  Home.    Illus.    $3.00 

STEELL.     Phyiical  Signs  of  Pulmonary  Disease.     Illus.       $1.25 


MEDICAL  BOOKS.  17 


MASSAGE.     PHYSICAL  EXERCISE. 

GULICK.  Physical  Education  by  Muscular  Exercise.  Illus- 
trated.    Just  Ready.  .75 

OSTROM.  Massage  and  the  Origin*!  Swediih  Movements. 
Their  Application  to  Various  Diseases  of  the  Body.  .A.  Manual 
for  Students,  Nurses,  and  Physicians.  Fifth  Edition,  En- 
larged.     115  Illustrations,  many  of  which  are  original.     $1.00 

MITCHELL  AlfD  GULICK-  Mechanotherapy.  Exercise,  Ortho- 
pedics, Massage,  Ocular  Corrections,  etc  Illustrated.  iSe# 
Cohtn,  Phyaiologic    Therapeutics,  below.     Just  Ready. 

TREVES.     Physical  Education.     Its  Value,  Methods,  etc.        .76 


MATERIA  MEDICA  AND  THERAPEUTICS. 

BRACKEN.  Outlines  of  Materia  Medica  and  Pharmacology.  $2.76 

COBLENTZ.  The  Newer  Remedies.  Including  their  Synonyms, 
Sources,  Methods  of  Preparation,  Tests,  Solubilities,  Doses, 
etc.     3d  Edition,  Enlarged  and  Revised.  $1.00 

COHEN.  Physiologic  Therapeutics.  Methods  other  than  Drug- 
Giving  useful  in  the  Prevention  of  Disease  and  in  the  Treat- 
ment of  the  Sick.  Mechanotherapy,  Mental  Therapeuticg, 
Suggestion,  Electrotherapy,  Climatology,  Hydrotherapy, 
Pneumatotherapy,  Prophylaxis,  Dietetics,  Organotherapy, 
Phototherapy,  Mineral  Waters,  Baths,  etc.  11  volumes,  8vo. 
Illustrated.      (Subscription.}  Cloth,  $27.50;  i  Mor.,  $38.50 

Special  Descriptive  Circular  xoill  be  tent  upon  application. 

GORGAS.  Dental  Medicine.  A  Manual  of  Materia  Medica  and 
Therapeutics.     7th  Edition,  Revised.  $4.00 

GROFF.  Materia  Medica  for  Nurses,  with  Questions  for  Self- 
Examination.     2d  Edition,  Revised  and  Improved.  $1.25 

HELLER.  Essentials  of  Materia  Medica,  Pharmacy,  and  Pre- 
scription Writing.  $1.50 

HEWLETT.     Serum-Therapy,  Vaccines,  etc.  $1.75 

POTTER.  Handbook  of  Materia  Medica,  Pharmacy,  and  Thera- 
peutics, including  the  Action  of  Medicines.  Special  Therapeu- 
tics, Pharmacology,  etc.,  including  over  600  Prescriptions  and 
FormulsE.  9th  Edition,  Revised  and  Enlarged.  With  Thumb 
Index  in  each  copy.  Cloth,  $5.00 ;  Sheep,  $6.00 

POTTER.  Compend  of  Materia  Medica,  Therapeutics,  and  Pre- 
scription Writing,  with  Special  Reference  to  the  Physiological 
.\ction  of  Drugs.     6th  Edition.  $1.00;  Interleaved,  $1.25 

MURRAY.     Rough  Notes  on  Remedies.     4th  Edition.  $1.25 

SAYRE.  Organic  Materia  Medica  and  Pharmacognosy.  An 
Introduction  to  the  Study  of  the  Vegetable  Kingdom  and  the 
Vegetable  and  Animal  Drugs.  Comprising  the  Botanical  and 
Physical  Characteristics,  Source,  Constituents,  and  Pharma- 
copeial  Preparations,  Insects  Injurious  to  Drugs,  and  Pharma- 
cal  Botany.  With  sections  on  Histology  and  Microtechnique, 
by  W.  C.  STBTBNa.  374  Illuatrations,  many  of  which  ara 
original.     3d  Edition.  In  Press. 

SCOVILLE.  The  Art  of  Compounding.  3d  Edition,  Revised 
and  Enlarged.     Just  Ready.  $2.50 


18  SUBJECT  CATALOGUE. 

TAVERA.     Medicinal  Plants  of  the  Philippineg.  $2.00 

WHITE  AND  WILCOX.  Materia  Medica,  Pharmacy,  Pharma- 
cology, and  Therapeutics.  5th  American  Edition,  Revised  by 
Rktnold  W.  Wilcox,  m.a.,  m.d.,  ll.d.,  Profesaor  of  Clinical 
Medicine  and  Therapeutics  at  the  New  York  Post-Graduate 
Medical  School.  Cloth,  $3.00 ;  Leather,  $3.50 

MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

REESE.  Medical  Jiirisprudence  and  Toxicology.  A  Text-Book 
for  Medical  and  Legal  Practitioners  and  Students.  6th 
Edition.     Revised  by  Henrt  Leffmann.  m.d. 

Cloth,  $3.00;  Leather,  $3.50 
"To  the  student  of  medical  jurisprudence  and  toxicology  it  is 

invaluable,  as  it  is  concise,  clear,  and  thorough  in  every  respect." 

— The  American  Journal  of  the  Medical  Sciencea. 

TANNER.  Memoranda  of  Poisons.  Their  Antidotes  and  Tests. 
9th  Edition,  by  Dr.  Hbnrt  LKrFUANN.  .75 

MICROSCOPY. 

CARPENTER.  The  Microscope  and  Its  Revelations.  8th 
Edition,  Revised  and  Enlarged.  817  Illustrations  and  23 
Plates.  Cloth,  $8.00;  Half  Morocco,  $9.00 

GREENISH.  Microscopical  Examination  of  Foods  and  Drugs. 
Illustrated.  $3.50 

LEE.  The  Microtomist's  Vade  Mecum.  A  Handbook  of 
Methods  of  Microscopical  Anatomy.  887  Articles.  5th 
Edition,  Enlarged.  $4.00 

OERTEL.  Medical  Microscopy.  A  Guide  to  Diagnosis,  Ele- 
mentary Laboratory  Methods  and  Microscopic  Technic.  131 
Illustrations.  $2.00 

REEVES.  Medical  Microscopy,  including  Chapters  on  Bacteri- 
ology, Neoplasms,  Urinary  Examination,  etc.  Numerous 
Illustrations,  tsome  of  which  are  printed  in  colors.  $2.50 

WETHERED.  Medical  Microscopy.  A  Guide  to  the  Use  of  the 
Microscope  in  Practical  Medicine.     100  Illustrations.         $2.00 

MISCELLANEOUS. 

BERRY.     Diseases  of  Thyroid  Gland.     Illustrated.  $4.00 

BUXTON.     Anesthetics.     Ihustrated.     3d  Edition.  $1.50 

COHEN.     Organotherapy.    See  Cohen,  Physiologic  Therapeutica, 

page  17. 

FRENKEL.     Tabetic  Ataxia.     Illustrated.  $3.00 

GOULD.  Borderland  Studies.   Miscellaneous  Essays.   12mo.  $2.00 

GOULD.      Biographic  CUnics.      Volume  I.      The  Origin  of  the 

Ill-Health    of    DeQuincy,     Carlyle,    Darwin,     Huxley,    and 

Browning.  $1.00 

GOULD      Biographic  Clinics.      Volume  II.     The  Origin  of  the 

Ill-Health    of     Waf?ner,    Parkman,    Mrs.    Carlisle,    Spencer, 

Whittier,  Ossoli,  George  Eliot,  and  Nietsche.  $1.00 


MEDICAL  BOOKS.  1» 


GREENE.     Medical    Examination    for    Life    Insurance.     Illus. 
With  colored  and  other  Engravings.     2d  Edition.       In  Preat. 
HAIO.     Causation  of  Disease  by  Uric  Acid.     The  Pathology  of 
High  Arterial  Ten.iion,  Headache,  Epilepsy,  Gout,  Rheuma- 
tism, Diabetes,  Bright'a  Disease,  etc.     6th  Edition.         $3.50 
HENRY.     A  Practical  Treatise  on  Anemia.  Half  Cloth,  .50 

OSGOOD.     The  Winter  and  Its  Dangers.  .40 

OSLER.     Essays  and  Addresses.  In  Press. 

PACKARD.     Sea  Air  and  Sea  Bathing.  .40 

RICHARDSON.     Long  Life  and  How  to  Reach  It.  .40 

ST.  CLAIR.  Compend  of  Medical  Latin.  2d  Edition.  In  Press. 
SCHEUBE.  Diseases  of  Warm  Countries.  "Illustrated.  $8.00 
TISSIER.     Pneumotherapy,    Aerotherapy,  Inhalation  Methods. 

See  Cohen,    Phytioloqic  Therapeutics,  page  17. 
TURNBULL.     Artificial  Anesthesia.     4th  Ed.     Illus.  $2.60 

WARDEN.     The  Paris  Medical  School.  Paper,  .75 

WEBER  AND  HINSDALE.     CUmatology  and  Health   Resorts. 
Including  Mineral  Springs.     2  vols.     Illustrated  with  Colored 
Maps.     See  Cohen,  Phyaioloaic  Therapeutics,  page  17. 
WILSON.     The  Summer  and  Its  Diseases.  .40 

WINTERNITZ.  Hydrotherapy,  Thermotherapy,  Phototherapy, 
Mineral  Waters,  Baths,  etc.  Illustrated.  See  Cohen,  Physio- 
logic Thtrapevttict,  page  17. 

NERVOUS  DISEASES. 

DERCUM.  Rest,  Suggestion,  Mental  Therapeutics.  See  Cohen, 
Physiologic  Therapeutics,  page  17. 

GORDINIER.  The  Gross  and  Minute  Anatomy  of  the  Central 
Nervous  System.  With  271  original  colored  and  other  Illus- 
trations. Cloth,  S6.00;  Sheep,  $7.00 

GOWERS.     Syphilis  and  the  Nervous  System.  $1.00 

GOWERS.     Manual    of   Diseases   of   the    Nervous   System.     A 
Complet«  Text-Book.     Revised,  Enlarged,  and  in  many  parts 
Rewritten.     With  many  new  illustrations.     Two  volumes. 
Vol.  I.  Diseases  of  the  Nerves  and  Spinal  Cord.     3d  Edition, 
Enlarged.  Cloth,  $4.00;  Sheep,  $5.00 

Vol.  II.  Diseases  of  the  Brain  and  Cranial  Nerves;  General  and 
Functional  Disease.     2d  Ed.  Cloth,  $4.00 ;  Sheep,  $5.00 

GOWERS.  Epilepsy  and  Other  Chronic  Convulsive  Diseases. 
2d  Edition.  $3.00 

GOWERS.  Clinical  Lectures.  Illustrated.  Second  Series. 
Just  Ready.  $2.00 

HORSLEY.  The  Brain  and  Spinal  Cord,  the  Structure  and 
Functions  of.     Numerous  Illustrations.  $2.50 

ORMEROD.  Diseases  of  the  Nervous  System.  e6  Wood  En- 
gravings. $1.00 

PERSHING.  Diagnosis  of  Nervous  and  Mental  Diseases.  Iliiis- 
tratad.  $1.26 

PRESTON.  Hysteria  and  Certain  Allied  Conditions.  Their 
Nature  and  Treatment.     Illustrated.  $2.00 

WOOD.     Brain  Work  and  Overwork.  .40 


20  SUBJECT  CATALOGUE. 

NURSING  (sec  also  Massage). 

Special  Catalogue  oj  Book*  for  Nurtet  tent  free  upon  application. 

CAinTELD.  Hygiene  of  the  Sick-Room.  A  Book  for  Nurses 
and  Others.  Being  a  Brief  Consideration  of  Asepsis,  Anti- 
sepsis, Disinfection,  Bacteriology,  Immunity,  Heating  and 
Ventilation,  and  Kindred  Subjects  for  the  Use  of  Nurses  and 
Other  Intelligent  Women.  $1.25 

CUFF.  Lectures  to  Nurses  on  Medicine.  4th  Edition.  $1.25 
DAVIS.    Bandaging.    Its  Principles  and  Practice.     163  Original 

Illustrations.  $1.50 

FULLERTON.  Obstetric  Nursing.  6th  Ed.  45  Illus.  $1.00 
FULLERTON.     Surgical  Nursing.     3d  Ed.     69  Illua.  $1.00 

GROFF.     Materia  Medica  for  Nurses.     With  Questions  for  Self- 

Examination.     2d    Edition,    Revised  and   Improved      $1.25 

HADLEY.  General,  Medical,  and  Sxirgical  Nursing.  A  very 
Complete  Manual,  Including  Sick-room  Cookery.  $1.25 

HUMPHREY.  A  Manual  for  Nurses.  Including  General 
Anatomy  and  Physiology,  Management  of  the  Sick-room,  etc. 
24th  Edition.     79  Illustrations.  $1.00 

STARR.  The  Hygiene  of  the  Nursery.  Including  the  General 
Regimen  and  Feeding  of  Infants  and  Children,  and  the  Domes- 
tic Management  of  the  Ordinary  Emergencies  of  Early  Life, 
Massage,  etc.     6th  Edition.     25  Illustrations.  $1.00 

TEMPERATURE  AND  CLINICAL  CHARTS.     See  pag*  25. 
VOSWINKEL.     Surgical  Nursing.     Second   Edition,   Enlarged. 
112  Illufltrationa.  $1.00 

WILCOX.     Fever  Nursing.     Juat  Ready.  $1.00 

OBSTETRICS. 

EDGAR.  Text-Book  of  Obstetrics.  By  J.  CLirroN  Ed«ar, 
M.D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Medical 
Department  of  Cornell  University,  New  York  City.  etc.  1221 
Illustrations.    Juat  Ready.  Cloth,  $6.00;  Sheep,  $7.00 

FULLERTON.     Obstetric  Nursing.     6th  Ed.     Illus.  $1.00 

LANDIS.  Compend  of  Obstetrics.  7th  Edition,  Revised  by 
Wm.  H.  W«ll8,  M.D.,  Demonstrator  of  Clinical  0bst«tric8, 
Jefferson  Medical  College.  52  Illus.  $1.00;  Interleaved,  $1.25 

WINCKEL.  Text-Book  of  Obstetrics,  Including  the  Pathology 
and  Therapeutics  of  the  Puerperal  State.     Illustrated.      $5.00 

PATHOLOGY. 

DANIEL.  Laboratory  Exercises  in  Tropical  Medicine.  Just 
Ready.  84.00 

BLACKBURN.  Autopsies.  A  Manual  of  Autopsies  Designed 
for  the  Use  of  Hospitals  for  the  Insane  and  other  Public  Insti- 
tutions.    Ten  full-pag«  Platen  and  other  Illustration*.     $1.26 

COPLIN.  Manual  of  Pathology.  Including  Bacteriology,  Tech  - 
nic  of  Post-Mortems,  Methods  of  Pathologic  Research,  etc. 
330  Illustrations,  7  Colored  Plates.     3d  Edition.  $3.50 


MEDICAL  BOOKS.  21 


DA  COSTA.  Clinical  Hematology.  A  Practical  Guide  to  the 
Examination  of  the  Blood.  Six  Colored  Plates  and  48  Illus- 
trations. Cloth.  $5.00;  Sheep,  $6.00 

LAZARUS-BARLOW.  Pathological  Anatomy.  With  7  Colored 
Plates  and  171  other  Illustrations.  $6.50 

LAZARUS-BARLOW.  General  or  Experimental  Pathology. 
Illustrated.     2d  Edition.     Just  Ready.  $6.50 

MacLEOD.  The  Pathology  of  the  Skin.  Colored  and  other 
Illustrations.  $5.00 

MARTIN.    Manual  of  Pathology.   Illustrated.   Just  Ready.  $4.00 

ROBERTS.     Gynecological  Pathology.     Illustrated.  $6.00 

THAYER.     Compend  of  Special  Pathology.     Illustrated. 

$1.00^  Interleaved,  $1.25 

THAYER.  Manual  of  General  and  Special  Pathology.  131 
Illustrations.  711  pages.  2d  Edition.  Full  Limp  Morocco, 
Gilt  Edges,  Round  Corners.  $2.50 

VIRCHOW.     Post-Mortem  Examinations.     3d  Edition.  .75 

WHITACRE.  Laboratory  Text-Book  of  Pathology.  With  121 
Illustrations.  $1.50 

PHARMACY. 

Special  Catalogue  of  Books  on  Pharmacy  sent  free  upon  application. 

COBLENTZ.  Manual  of  Pharmacy.  A  Complete  Text-Book  by 
the  Professor  in  th«  New  York  College  of  Pharmacy.  2d  Ed., 
Revised  and  Enlarged.     437  III  us.     Cloth,  $3.50;  Sheep,  $4.50 

COBLENTZ.     Volumetric  Analysis.     Illustrated.  $1.25 

BEASLEY.  Book  of  3100  Prescriptions.  Collected  from  the 
Practice  of  the  Most  Eminent  Physicians  and  Surgeons — Eng- 
lish, French,  and  American.  A  Compendious  History  of  the 
Materia  Medica,  Lists  of  the  Doses  of  all  the  Officinal  and  Es- 
tablished Preparations,  an  Index  of  Diseases  and  their  Reme- 
dies.    7th  Edition.  $2.00 

BEASLEY.  Druggists'  General  Receipt  Book.  Comprisii^  a 
Copious  Veterinary  Formulary,  Recipes  in  Patent  and  Pro- 
prietary Medicines,  Druggists'  Nostrums,  etc. ;  Perfumery  and 
Cosmetics,  Beverages,  Dietetic  Articles  and  Condiments,  Trade 
Chemicals,  Scientific  Processes,  and  many  Useful  Tables. 
10th  Edition.  $2.00 

BEASLEY.  Pharmaceutical  Formulary.  A  Synopsis  of  the 
British,  French,  German,  and  United  States  Pharmacopceias. 
Comprising  Standard  and  Approved  Formulae  for  the  Prepara- 
tions and  Compounds  Employed  in  Medicine.    12th  Ed.  $2.00 

GREENISH.  Microscopical  Examination  of  Foods  and  Drugs. 
Illustrated.  $3.50 

ROBINSON.  Latin  Grammar  of  Pharmacy  and  Medicine.  4th 
Edition.     With  elaborate  Vocabularies.     Just  Ready.     $1.50 

SAYRE.  Organic  Materia  Medica  and  Pharmacognosy.  An 
Introduction  to  the  Study  of  the  Vegetable  Kingdom  and  the 
Vegetable  and  Animal  Drugs.  Comprising  the  Botanical  and 
Physical  Characteristics,  Source,  Constituents,  and  Pharma- 
copeial  Preparations,  Insects  Injurious  to  Drugs,  and  Phar- 
macal  Botany.  With  sections  on  Histology  and  Microtech- 
nique, by  W.  C.  Stkvkns.     374  Illuatrationa.    Third  Edition. 

In  Press. 


22  SUBJECT  CATALOGUE, 

SCOVILLE.  The  Art  of  Compounding.  Third  Edition.  Re- 
vised and  Enlarged.     Just  Ready.  Cloth,  $2.50 

STEWART.  Compend  of  Pharmacy,  Based  upon  "Reming- 
ton's Text-Book  of  Pharmacy."  5th  Edition,  Revised  in 
Accordance  with  the  U.  S.  Pharmacopoeia,  1890.  Complete 
Tables  of  Metric  and  English  Weights  and  Measures. 

$1.00;  Interleaved,  SI. 25 

TAVERA.     Medicinal  Plants  of  the  Philippines.  $2.00 

UNITED  STATES  PHARMACOPCEIA.  7th  Decennial  Revision. 
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TYSON.     Cell  Doctrine.     Its  Historj-  and  Present  State.     $1.50 


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Guy's  Hospital ;  Consulting  Surgeon  Royal 
Hospital  for  Children  and  Women ;  and  F. 
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nearly  1000  illustrations  and  lithograph  plates,  inserted  wherever 
they  could  be  used  to  advantage.  Can  be  used  by  students  of 
any  college.  They  contain  information  nowhere  else  collected  in 
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POTTER.  HUMAN  ANATOMY.  Seventh  Edition.  138  Illus- 
trations and  16  Plates  of  Nerves  and  Arteries. 

HUGHES.  PRACTICE  OF  MEDICINE.  Parti.  SiithEdition, 
Enlarged  and  Improved. 

HUGHES.  PRACTICE  OF  MEDICINE.  Part  H.  Sixth  Edition, 
Revised  and  Improved. 

BRUBAKER.     PHYSIOLOGY.     Eleventh  Edition.    lUus. 

LANDIS.     OBSTETRICS.     Seventh    Edition.     52    Illus. 

POTTER.  MATERIA  MEDICA,  THERAPEUTICS,  AND  PRE- 
SCRIPTION WRITING.     Sixth  Revised  Edition. 

WELLS.     GYNECOLOGY.     Third  Edition.     145  lUus. 

GOULD  AND  PYLE.  DISEASES  OF  THE  EYE.  Second  Edi- 
tion.    Refraction,  Treatment,  Surgery,  etc.     109  Illus. 

HORWITZ.  SURGERY.  Including  Minor  Surgery,  Bandaging, 
Surgical  Diseases,  Differential  Diagnosis  and  Treatment. 
Fifth  Edition.  With  98  Formulae  and  71  Illustrations. 

LEFFMANN.  MEDICAL  CHEMISTRY.  Fourth  Edition.  In- 
cluding Urinalysis,  Animal  Chemistry,  Chemistry  of  llUk, 
Blood,  Tissues,  the  Secretions,  etc. 

STEWART.  PHARMACY.  Fifth  Edition.  Based  upon  Prof. 
Remington's  Text-Book  of  Pharmacy. 

BALLOU.  EQUINE  ANATOMY  AND  PHYSIOLOGY.  29  graphic 
Illustrations. 

WARREN.  DENTAL  PATHOLOGY  AND  DENTAL  MEDICINE. 
Fourth  Edition,  Illustrated. 

HATFIELD.     DISEASES  OF  CHILDREN.     3d  Edition. 

ST.  CLAIR.     Medical  Latin.     2d  Edition.  In  Press. 

SCHAMBERG.  DISEASES  OF  THE  SKIN.  Third  Edition, 
Revised  and  Enlarged.     106  Illustrations. 

GUSHING.     HISTOLOGY.     Illustrated.  In  Press. 

THAYER.     SPECIAL  PATHOLOGY.     34  Illustrations 

KYLE.  DISEASES  OF  THE  EAR.  NOSE,  AND  THROAT. 
85  Illustrations. 

27 


DA  COSTA 


Clinical   Hematology 


A  Practical  Guide  to  the  Examination  of  the  Blood  by 
Clinical  Metliods.  With  Reference  to  the  Diagnosis  of 
Disease.     With  Colored  Illustrations.  Cloth,  ^^5.00 

*^*  A  new,  thorough,  systematic,  and  comprehensive 
work,  its  purpose  being,  first,  to  show  how  to  examine  the 
blood,  and  second,  how  to  diagnose  from  such  examination 
diseases  of  the  blood  itself  and  general  diseases.  The 
author's  aim  has  been  to  cover  not  alone  the  field  of  original 
research,  but  to  supply  a  book  for  the  student,  the  hospital 
physician  and  the  general  practitioner.  It  will  be  found 
wanting  in  none  of  these  respects. 

THAYER 


Manual  of  Pathology 


GENERAL  AND  SPECIAL 


Second     Edition.       i  3 1     Illustrations.       7 1 1 

izmo.        Full     Limp      Morocco,     Gilt     Edges, 
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This  book  shows  evidence  of  clinical  as  well  as  pathologi- 
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28 


The  Pocket  CyclopediaL  of 
Medicine   and   Surgery 

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With  Thumb  Index,  $U5 

Uniform  iviih  '*  Gould's  Pocket  Dicfionary  " 


A  concise  practical  volume  of  nearly  600 
pages,  containinj;  a  vast  amount  of  infor- 
mation on  all  medical  subjects,  including 
Diagnosis  and  Treatment  of  Disease, 
with  Formulas  and  Prescriptions,  Emer- 
gencies, Poisons,  Drugs  and  Their  Uses, 
Nursing,  Surgical  Procedures,  Dose  List 
in  both  English  and  Metric  Systems,  etc. 

By  Drs.  Gould  and  Pyle 

Based  upon  tfieif  large  **  Cyclopedia  of 
Medicine  and  Surgery/'     ,^      ji      ^ 


*^*  This  is  a  new  book  which  will  prove  of  the  greatest 
value  to  students.  It  is  to  the  broad  field  of  general  medi- 
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words.  The  articles  are  concise  but  thorough,  and  arranged 
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classified,  so  evenly  distributed,  so  methodically  grouped. 
It  is  Multum  in  Parvo.  Sample  Pages  Free. 
29 


EDGAR'S 

OBSTETRICS 

A   NEW   TEXT -BOOK 
1 22 1    Illustrations 


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other  works  on  this  subject 
in  completeness,  in  uni- 
formity and  consistency  in 
arrangement,  thoroughness 
and  clearness  in  handling 
details,  and  in  the  number 
and  usefulness  of  its  illus- 
trations.     See  page  20. 

OCTAVO.      CLOTH,   $6.00;    SHEEP,   I7.00 


5f  :^v' 


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